C09976240 / invoice 10000

REASON- Ear recheck 

HISTORY-
Presenting for an ear recheck. 
Had a course of osurnia in the L ear. 
Noticed an improvement in the ears signs. Not liking the owner looking at them. 
Seems to be scratching less at them. 
EDDU - normal.
Medications: fluoxetine SID
A very anxious girl but did not tolerate traz well. 

BAR
BCS 5/9
HR:  110bpm, difficult auscultation due to trembling. Pulses S+S
RR:   panting, normal respiratory sounds and effort. 
T:    not performed
CRT: 1sec    
MM: pink & moist
EYES: NAD
EARS: Nil discharge, nil pinnal erythema, nil ear canal stenosis. Comfortable with swabbing today. 
NOSE: NAD
ORAL EXAM: Grade 1/4 periodontal disease. Mild tartar, nil gingivitis. 
SKIN:  NAD
ABDOMINAL PALPATION: Not performed. 
MUSCULOSKELETAL SYSTEM: Ataxic gait & wobbling. Intention tremors. Hypermetric gait. 

CYTOLOGY:
Manual smear performed:
L ear: Malassezia (only 2 cells seen per entire scan)
R ear: Nil microorganisms

ASSESSMENT:
Resolution of OE

PLAN:
- Recommended regular ear cleans, suggested O to use otoflush. O to clean fortnightly/weekly

Rx:
N/A

Used last fluoxetine script on file. BC

REASON: 2nd Osurnia

History: Owner said she is still scratching at the ear but it has subdued a little bit.
Also mentioned she seems a bit more wobbly on new medication - Trazodone? (Owner spoke to Ari and unsure which medication she meant)
Is booking in with vet in two weeks time to re-check ears and can discuss medications then (or sooner if concerned)

Rx: Osurnia applied to LEFT ear.
AF