C09974989 / invoice 10000

23/02/2026 Reason:  
History: 
this time of year gets a bit itchy 
- paws and ears 

yesterday noticed swelling on R ear 

started fish oils about a month ago 

has noticed RFL sore when getting up from rising 

Current medications: 1000mg paracetamol PRN 

Examine: 
Mentation: BAR - nervous
Body condition score: 
MM:  PM              CRT: <2
HR: 90               RR: pant
LN: NSF
Temperature: nt

Ocular: NSF
Oral/Dental stage: 1-2
Ears: R 2-3cm aural haematoma. mild brown waxy discharge bilaterally - TM intact bilaterally 
R ear cytology + yeast, + cocci
L ear cytology + yeast, + cocci 
Cardiovascular: NSF
Respiratory: NSF
Gastrointestinal: NSF
Integumentary & lumps (measurement, location): NSF
Musculoskeletal: NSF
Urogenital: NSF
Neurological: NSF

Problem List:
Aural haematoma 

bilateral OE 

Assessment: 
discussed draining vs surgery - o opted to drain it given breed and age 
will treat infection with steroids and topical meds 

Treatment: 
nummit applied and drained in consult 
dermotic BID in both ears 
30mg tapering dose of pred 

Plan: 
recheck in 10 days 

On-going medications required: Y/N (use prescription tab for further supply):

Followup:  | 02/03/2026 Revisit reason:
History:
- In today for recheck of previously drained aural haematoma. O reports it has come back since being drained
- Still shaking head half a dozen times per day

Medications: 
- Prednisolone 20mg SID
- Dermotic 1ml BID both ears
EDUF: Normal
Mentation: BAR
BCS (0-5): 2.5/5
HR: 100 w/ no murmur or arrythmia
RR: WNL w/ no adventitious lung sounds
MM: PM
CRT: <2sec
Temperature: NE

Any additional findings:
- Aural haematoma (O reports 3/4 of original size). Soft.

Cytology: malassezia + 1-3/hpf.

Assessment:
- Advised revisit in a week for recheck of infection and aural haematoma. Advised if I redrain it, it will likely come back. Advised waiting and seeing how it goes. Surgery is possible, but may still not resolve the issue

Treatment:
- Continue pred and dermotic

Plan: 
- RV in a week