C09977374 / invoice 10000

Reason: Ongoing Ear Infection CCCBAppointment Notes: Unsure which ear it was, red and irritated, attempting to scratch .EDDU wellSUMMARY:- Presented for head shaking and red ears.- Diagnosed with bilateral otitis externa based on cytology.- Left ear has a yeast overgrowth; right ear has a bacterial infection.- Dispensed Dermotic for treatment.- Recheck scheduled in one week to assess response and discuss management of recurrent infections.HISTORY:- Owner noted red ears this morning.- Associated head shaking reported.- History of ear infection in November 2025, treated with Dermotic.- Anal glands expressed in November 2025.Current meds: noneVaccination: UTDParasite prevention: UTDPre-existing conditions: recurrent otitis externaCurrent diet: not discussedEXAMINATION:Body Condition Score: 7-8/9Hydration status (%): hydration clinically adequateCardiovascular: cardiac auscultation normal, normal rate & rhythmRespiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: appropriate mentation and no obvious neurological deficits detectedMusculoskeletal: ambulating normally, no obvious musculoskeletal abnormalities identifiedGastrointestinal:- Oral: not assessed- Abdominal: Not performed- Rectal: Not performedIntegument/Ears: Bilateral otitis externa. Erythema noted L>RLymph Nodes: NSFEyes: NSFLABORATORY:- Ear Cytology: malassezia 2+ identified in the left ear. Bacteria (cocci) 3+ identified in the right ear.ASSESSMENT:- Bilateral otitis externa (L: Malassezia, R: bacterial).- Recurrent otitis.- Overweight.TREATMENT:- Dermotic ear drops dispensed.- Instructions: Apply 1 ml into each ear twice daily for 7 days.PLAN:- Recheck consultation in one week for follow-up otoscopy and cytology.- Discuss initiating a maintenance anti-inflammatory ear drop if infections recur.- Recommended Glandex supplement to support natural anal gland emptying.- Recommended instituting a weight management plan.CLIENT COMMUNICATION:- Discussed examination and cytology findings with the owner.- Explained the nature of yeast and bacterial overgrowth in the ear canal.- Advised on the importance of the recheck appointment to ensure resolution.- Discussed the potential for prophylactic treatment for recurrent infections.- Discussed weight gain (from 19 kg in September 2025 to 21.8 kg).- Advised on dietary management, including weighing food for accuracy.    Vital Signs    Weight: 21.8;