C09977763 / invoice 10000

Presented for -  check ears

Hx: O noticed a bit of redness & gunk from one of her ears a few days ago. Has been using ear cleaner to keep it clean but gunk keeps coming back. 

Mentation: QAR, anxious today - wanting to jump off table (so PE limited & brief to focus on ears)  
EDUF: all normal 
MM: p/m
CRT: <2s
Skin tent: normal turgor
LN: nad 
Ears: 
- L ear: very mild amount of tan-brown discharge at bottom of canal (wax vs exudate), TM intact 
- R ear: moderate amount of tan-brown discharge/exudate in canal, TM intact, minimal erythema
Eyes: nad 
HR: 132bpm = PR  
Chest Auscultation: normal bronchiovesicular sounds  
Abdo Palpation: tense but comfortable
Skin: nad 
Joints/Gait:ambulatory 
Urogenital: nad 

Vaccination status: due April 2026. 
 
Problem list: 
1) Bilateral OE (R > L)

Treatment in clinic:
- Cytology: R ear: 50/hpf malassesia, occ cocci. L ear: 5-10/hpf malassesia 
- Easotic: 1st dose applied to each ear. 

Plan:  Recommend RV in 10-14 days for ear recheck  

Communication: RC 

Presented for vaccination. Also check ears - R ear seen at last visit going really well but has started scratching L ear for the past few days. L ear looks quite red. 

Exam: BAR
EDUF: well
MM: moist pink
CRT: 1s
DS: 0/4
LN: nad
Ears: 
* LEFT ear - moderate erythema external pinna and also down canal, brown ceruminous dch down canal, TM intact. Cytology malessezia and cocci 3+
R ear nad, clear to TM, TM intact
Eyes:nad 
HR:  140bpm, nil m/a
Chest Auscultation: nad
Abdo Palpation: nad
BCS: 5/9
Temp: not taken
Skin: nad
Joints/Gait: no lameness in consult, full ortho exam not performed

Plan: 
Recheck L ear 10 days

Vaccine Batch numbers:
Nobivac DHP: 2412905, 04-2026
Nobivac Bp/Pi: 2503810, 10-2026
 
Nobivac Tricat:
Nobivac Ducat:
Leucogen FeLV:
Fel-O-Vac FIV:

Presented for -  itchy ears
got worse over weekend,O have been cleaning saline
desexed 4 weeks ago, cyst nose getting smaller


Current medications: amoxy clauv finishing dose
Parasite control: 

Mentation: BAR 
EDUF: nad
MM: pink moist
CRT: < 2sec
DS: 0/4
Skin tent: < 1sec
Ears: R ear inflamed external, stenotic, L ear nad
Eyes: clear
Thyroid: wnl
HR:  110 reg no murmur
Chest Auscultation: normal bronchovesicular sounds
Abdo Palpation: soft
BCS:5 /9
Temp: np
Rectal Exam:  np
Skin: intact
Joints/Gait:ambulating well in consult
Urogenital: 
Vaccination status: UTD
 
Problem list: 
1) otitis externa R ear
DDx:

Treatment in clinic: cytology 
r) earTM intact, ceruminous exudate, malasezia +++, cocci ++, very stenotic canal

Plan: dermotic R ear biD 7 days
prednisilone 5mg sid 5 days then taperdose
re-check 10 days

Communication: discussed with O monitor SE any D or V stop pred, re-check 10 days