C09978843 / invoice 10000

Reason: AHT?Subjective: Presenting Concerns:  Hugo presented for a flare-up of his L ear, which has been ongoing but has worsened over the last 3-4 days with increasing swelling. The owner also reports a history of chronic allergies.    Historical Conditions:-   History of chronic environmental allergies, which are reportedly worse in summer and better in winter.-   Previous treatment with Cytopoint injections, with the owner reporting decreasing efficacy over time and concerns about the cost.-   History of a digit fracture on RHL at approximately 2 years of age.-   The patient is entire.  Diet/Appetite:-   Diet: Meals for Mutts dry food (Salmon and Sardine flavour).-   Treats: Carrots and occasional pig's ears.  Skin & Coat:-   The owner reports that the patient is constantly itchy due to allergies.-   The owner has Malaseb medicated shampoo at home but has not been adhering to the recommended 10-15 minute contact time.-   The owner is concerned the patient may be rubbing his ear against an asbestos fence.  Current Medications:-   No current medications are being administered.  Lifestyle Risk Factors:-   Goes for walks through grassy areas.Objective: Mentation: BAR  BCS: 5/9  T: Not taken  HR: 80 bpm  RR: pantingMM: pink/moist. CRT < 2sec.    Emotional Assessment:  The patient was cooperative for the examination.    Eyes: Mild conjunctivitis noted bilaterally. The L eyelid appears slightly droopy, possible facial nerve paralysis?Ears:-   Left Pinna: A large aural haematoma is present at the base of the pinna. Approx 5-7cm-   L ear Canal: The external ear canal is inflamed with a yellow, purulent discharge present. Otoscopic examination revealed the deeper portion of the canal appears normal. Unable to visualise TM due to inflammed canal-   R ear: The pinna and ear canal appear normal with no inflammation or discharge noted on otoscopic examination.Nose: Clear, moist without discharge.  Oral: Calculus and gingivitis absent. No masses or other lesions. The skin underneath the muzzle is erythematous and inflamed. The left lip commissure appears to be drooping.  Cardiovascular: No murmurs or arrhythmias, strong synchronous pulses.  Respiratory: Normal bronchovesicular sounds bilaterally.  Abdominal: No organomegaly or mass effects. No pain on palpation.  Lymph Nodes: No peripheral lymphadenopathy.  Integumentary: Superficial ulceration and patchy alopecia are present on the dorsal aspect of the paws. Alopecia is present on the lateral aspect of RH paw, which the owner reports has been present since a previous fracture. The skin on the ventral aspect of the muzzle is erythematous and inflamed. No evidence of ectoparasites.  Neurologic: Facial drooping is noted on the left side, affecting the ear, eyelid, and lip. This is suspected to be secondary to the otitis externa affecting the facial nerve. No ataxia, normal mentation.  Musculoskeletal: Ambulation normal, no lameness observed.  Rectal: Not performed.    Point of Care Diagnostics:-   Ear Cytology (L ear): A mixed population of yeast and bacteria was identified.-   Ear Cytology (R ear): No infectious organisms or significant inflammation seen.Assessment: Aural Haematoma, Left Pinna – This is secondary to self-trauma (head shaking and scratching) resulting from the underlying otitis externa.    Otitis Externa, L ear – A mixed bacterial and yeast infection was confirmed on cytology. The chronic and unilateral nature of the infection is suggestive of an underlying allergic cause.    Suspected Atopic Dermatitis – The patient has a history of chronic, seasonal pruritus (worse in summer) and skin lesions affecting the paws and muzzle. The diet history makes a food allergy less likely, supporting an environmental cause. The current skin lesions show evidence of secondary superficial pyoderma.    Facial Nerve Paralysis, Left Side – Characterised by drooping of the L ear, eyelid, and lip. This is suspected to be a consequence of the severe, chronic inflammation associated with the left-sided otitis externa.Plan: Medications/Treatments:-   An aural haematoma drainage will be performed today. The haematoma will be aspirated with a needle, and a steroid will be instilled into the pinna.-   Oral antibiotics and steroids will be prescribed to manage the secondary superficial pyoderma and to reduce inflammation and pruritus.-   The use of Malaseb shampoo was discussed. It is recommended to bathe the patient q 2-3 days, ensuring a contact time of 10-15 minutes before rinsing to improve efficacy.-   Advised O to clean ulcerated skin areas with dilute betadine  Additional Discussion:-   A recheck appointment is recommended for early next week (Monday or Tuesday) to assess the aural haematoma. A second recheck will be scheduled approximately one week later to re-evaluate the otitis.-   The long-term management of atopic dermatitis was discussed. Once the acute flare-up is controlled with steroids, a transition to zenrelia (a daily oral tablet) was proposed as an alternative to Cytopoint injections. The owners are agreeable to trying this approach.-   A referral to a veterinary dermatologist was discussed for intradermal allergy testing and potential immunotherapy. The cost was estimated to be around $2,000 for intradermal testing alone. It was explained that the goal of immunotherapy is to reduce the reliance on medication, not necessarily to provide a complete cure. A referral will considered at recheck appt, allowing the owners to schedule an appointment in the future if they choose.-   The surgical option for repairing the aural haematoma was explained as a salvage procedure if medical management is unsuccessful.-   The owners gave consent for the consultation to be recorded.    Vital Signs