C09980686 / invoice 10000

ear recheck

much improved clinically at home

cytology
ear midly better. no bacteria, still 10-20 yeast/hpf R ear
L ear normal
neptra still working for another week

start elocon every second day starting in 1 week
recheck in 1 month

Vaccination

History 
Eating well, drinking well, normal stool, urinating normally.
Problems: anxiety, hx of ear infections (rods at last visit), yesterday had a bit of head tilt and seemed uncomfortable momentarily, no freq scratchign at ears
Existing medications: fluoxetine 20mg 1 tab PO SID
Heartworm Prevention: NG spectra
Flea and tick control: NG spectra

Physical examination

Mouth - dental disease grade 1
Ears - L ear nad scant discharge no inflammation, R ear erythematous + pruritic on swabbing and copious black-brown discharge
Eyes - conjunctiva and orbit normal
Skin and coat - normal
Chest - thoracic auscultation normal, Heart Rate = 100
Abdomen - all abdominal viscera palpate normally
Limbs - no lameness detected

Cytology:
R ear yeast 2+, cocci 2+, no rods today
L ear nsf scant cocci

Plan 
Client has difficulty medicating ear at home. Administer neptra into R ear. Attempted ear clean prior but Nella very sensitive and became reactive. 

Fit to Vaccinate
- Nobivac lepto BNA003A01 EXP 10-2026 SC dorsal
- Nobivac KC Intranasal BN 2511209 EXP12-2027 intranasal

Recommendations:
Intestinal worming three monthly
RV in 7 days to recheck R ear. 
If doing well consider maintaining with elocon steroid ointment as maintenance anti-inflammatory for ear canal (have ordered in for client)

 

ANIMAL PRESCRIPTION
This prescription is for ANIMAL USE ONLY

PRESCRIPTION MEDICINE
Drug Name: Fluoxetine 

Strength: 20mg

Quantity to be dispensed on each occasion: 28

Dose: Please give ONE tablet once daily

Route: By mouth

Number of repeat supplies: 6

Expiry Date: 29/06/2026

Prescribing veterinarian: Dr Felicia Tam BVSc BSc(Vet) N10039