C09976969 / invoice 10000

Reason: RecheckAppointment Notes: ------- Sms reply: YHISTORY:Recheck consultation for a previously diagnosed right ear infection. The owner reports adherence to the 10-day treatment course. No recent paw licking or itching noted.Cytopoint injection was administered on 19/02/2026. Owner notes the effect may be wearing off, as itching sometimes returns towards the end of the monthly cycle.The owner bathed the dog yesterday with an oatmeal-based product.Current meds: noneVaccination: UTDParasite Prevention: UTDPre-existing conditions: skin allergies, resected MCT on left muzzle. Access to toxins eg. Rodenticide:noneDiet: The diet was increased from 1.5 cups twice daily to 2 cups twice daily due to previous weight loss. EXAMINATION:Body Condition Score: 5/9Pain Scale (0-4): 0/4Hydration status (%): hydration clinically adequateCardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory:thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological:neurologically no significant findingsMusculoskeletal: ambulating normally, no palpable neck, spine, limb or joint painGastrointestinal:- Oral: normal, no mouth pain, dental score (1-4):grade 1 - Abdominal: no detectable pain on abdominal palpation- Rectal: not performedUrinary: NSFReproductive: NSFIntegument/Ears: Right ear canal is clean and smells normal, indicating resolution of the infection.Lymph Nodes: NSFEyes: NSFDemeanour/Behaviour: not discussedPROBLEM LIST:1. Resolved Otitis Externa (Right Ear)2. History of Atopic DermatitisDIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:Resolved Otitis Externa (Right Ear)DIAGNOSTICS:None. Ear cytology was offered but declined by the owner due to financial considerations and clinical resolution.ASSESSMENT:Presented for a recheck of a right ear infection. On examination, the ear canal is clean and non-odorous, consistent with resolution of the infection. Lymph nodes are normal. Body condition is slightly increased. The underlying atopic dermatitis is managed with Cytopoint, which may be showing a reduced duration of efficacy.TREATMENT:The diet has been adjusted back to 1.5 cups twice daily to manage weight.PLAN:Continue monitoring for any signs of itching or recurrence of ear infections, particularly towards the end of the Cytopoint cycle.Owner to apply neocort cream if pruritis returns towards end of cytopoint cycle. If otitis recurs, a twice-weekly steroid ear treatment may be required.Next Cytopoint injection is due in approximately two weeks.Home into owner's care.CLIENT COMMUNICATION:Discussed the resolution of the ear infection. Advised the owner on dietary adjustment to manage the dog's weight. Discussed the plan for managing potential flare-ups of skin disease as the Cytopoint injection wears off, including options for topical and ear treatments. The owner is aware of the need to monitor for signs and to return for the next scheduled injection.    Vital Signs    Weight: 30.7;