C09977133 / invoice 10000

Reason: Ear InfectionAppointment Notes: bad ear infectionConsultation Time: 21.00History: Ow has adopted since last May and do not know previous allergy historyEDDU fineNo V/DOw has noticed a hot spot on y'day and clipped and cleanedSince 3 pm it has got worsenAlso ears have some dischargesOw has taken to the beach recently however after come home, she does dry Leny wellNo other concernSubjective: BARObjective: Temp   38.3         MM  pink            CRT < 2 sec             HR  148           FP S+RBCS:   7/9                       Wt: 42  kgPain Score (CSU):  1 /4CV:  NAD       RESP:   NAD           RR Panting GIT:   Dental grade 2-3U/G:  NADNeuro:  NADM/S:  NADInteg:  7--8 cm diameter moister dermatitis below the left earsBoth ears had brown discharges,  Yeast +++Ophth:  Bilateral SNS LNs: NADProblem List:Integ:  7--8 cm diameter moister dermatitis below the left earsBoth ears had brown discharges,  Yeast +++Over weightDental garde 2Assessment: Moist Dermatitis with bilateral otitis predominately with yeastOptions Offered to Client:Treatment:Plan:Today, we have seen and are treating Lenny for two conditions: acute moist dermatitis (hot spot) and a bilateral ear infection. Below are the discharge instructions for both conditions.HOT SPOTS (ACUTE MOIST DERMATITIS)What are hot spots?Hot spots, also known as acute moist dermatitis, are rapidly developing skin sores that typically occur under the hair coat. While more common in thick-coated or long-haired dogs, they can occur in any breed. These sores are usually found in areas where the hair coat is dense, such as the back, tail base, neck, or face, and they tend to develop more frequently in hot, humid weather.Hot spots begin as a superficial skin injury that traps moisture under the hair coat, allowing bacteria to grow, causing further inflammation. The lesion often expands rapidly, with the skin becoming red, moist, and covered in a pus-like discharge. Although uncomfortable, hot spots are not life-threatening and typically heal well with treatment.TreatmentHair Clipping & Skin Cleaning: The affected area has been clipped and cleaned. This is a crucial step to prevent further infection. The clipping should be done just beyond the edge of the visible lesion, but avoid doing this at home as it may cause further injury. Sedation may be required for painful areas.Topical Medication: An antibiotic or antiseptic preparation has been applied to the area to control bacterial growth. This treatment may include a corticosteroid or analgesic to help alleviate pain.Follow-Up Care: Most hot spots heal within 3-5 days with appropriate treatment. If the infection extends deeper into the skin, antibiotics may be necessary.PreventionRegular grooming, especially for long or thick-coated dogs, to remove foreign materials such as plant matter.Flea control to prevent skin irritation.Treating any underlying conditions such as allergies promptly to prevent recurrence.If a hot spot develops, treat it immediately.Specific Instructions:Elizabethan Collar: Ensure that Lenny wears the Elizabethan collar provided at all times to prevent licking or scratching of the affected area. Ensure Lenny can eat and drink with the collar in place.Monitoring: Monitor the affected area closely. We expect the redness to diminish and the wound to begin drying within 2-3 days. If the area continues to weep, it can be bathed with saline solution (available from pharmacies). Do not use other antiseptic products unless advised by your veterinarian.Exercise Restriction: Keep Lenny indoors and limit physical activity. Leash walks are permitted.Diet: Lenny can continue his regular diet with free access to water. Ensure he continues to eat and drink, and monitor his toilet habits.Recheck: Please schedule a follow-up appointment with your regular veterinarian in 10-12 days for re-assessment, or earlier if Lenny's condition worsens or if you have concerns.OTITIS EXTERNA (EAR INFECTION)Lenny has also been diagnosed with otitis externa, an inflammation of the external ear canal. Symptoms of ear infections often include head shaking, ear rubbing, pain when touched around the ears, and sometimes an abnormal or smelly discharge.There are many potential causes of otitis externa, including:Skin allergiesEar mitesForeign bodies (such as grass seeds)Excess moisture from swimming or bathingNarrow or hairy ear canals (common in long-eared dogs)Often, otitis externa leads to a secondary bacterial or yeast infection. In some cases, laboratory tests (culture and sensitivity) may be required to determine the specific type of infection and tailor the treatment accordingly.TreatmentEar Medications: Please administer any prescribed ear drops or medications as directed by your veterinarian. It is important to follow the instructions carefully. If you have any questions about administering the ear drops, please contact your regular veterinarian.Cleanliness: If advised by your veterinarian, gently clean Lenny's ears to remove debris or discharge. However, avoid over-cleaning, as this can irritate the ear canal.Long-Term ManagementIf Lenny has recurrent ear infections, please discuss with your regular veterinarian long-term prevention strategies. This may include routine ear cleaning, changing his diet, or treating underlying conditions like allergies.IMPORTANT NOTESMonitor Lenny’s Condition: Over the next few days, you should see improvement in both conditions. If you notice any worsening symptoms or new concerns, please contact your veterinarian immediately.Emergency Care: If Lenny shows signs of significant pain, difficulty eating or drinking, or any unexpected reactions to the medications, seek emergency care.Follow-Up: Ensure that Lenny is seen by your regular veterinarian for re-evaluation in 10-12 days, or sooner if any issues arise.Thank you for visiting the AEC with Lenny. If you have any further questions or concerns, don't hesitate to reach out. We wish Lenny a swift and comfortable recovery!    Vital Signs    Weight: 42;