C09978275 / invoice 10000

Reason: Pruritic, ear infection both earsSubjective: EDDU normally, No V+ or d+O reports ear issues recurring every 3-4 months. Last ear infection treated previously, responded well to Cytopoint injection. Dog scratches at ears. O reports difficulty administering ear drops at home - dog resistant to treatment. No ear cleaning performed at home due to patient non-compliance and O time constraints.Objective: BARHR/PR/Cardio: pulse normal and synchronous, CV normal, no audible murmurTemp: neMM/CRT/Hydration: pink, moist CRT 1 sec, hydration normalRESP/RR: NAD normal rate and effortGIT/UG: NAD comfortableSkin/Ears: Both ears red and inflamed with brown discharge, malodorous. R ear worse than L. Cytology reveals large amounts of Malassezia, minimal bacteria both ears. Pruritic.M/S: NADEyes: NADDental: cleanLymph Nodes: wnlBCS: 5/9Assessment: Bilateral otitis externa - Malassezia. Secondary to underlying allergic skin disease.Treatment: Bedinvetmab (Cytopoint) SQ injection given today. Ear drops (Malassezia treatment) dispensed with small syringes for administration - 1 mL per ear BID for 7 days.Plan: Treat ears with drops as dispensed - 1 mL per ear BID x 7 days, massage well after administration. Consider more frequent Cytopoint injections (monthly vs current 3-4 monthly) to reduce allergic flares and potentially space out ear infections. O to monitor - if early pruritis noted, may administer Cytopoint before ear infection develops. Clinic available to assist with ear cleaning if needed at no charge. Recheck PRN or if not responding to treatment.____________________________INSURANCE HXInitial Assessment >  OE Suspected cause >  allergies, debris, weather Date of first clinical signs > 1 wk Any other conditions / treatments >  no     Vital Signs