C09982857 / invoice 10000

Appointment Notes: VETSTORIA -  - Roger (Dog) - Ray Mackenzie - 0422002324 - Consult - Eyes, Skin, Ears [Clinician : Dr Andres Townsend ( Senior Surgeon ) (Preferred Clinician)] - Ears Eyes Skin -Web BookingClient name: Ray MackenzieContact number: 0422002324Email address: mackrl@bigpond.comPatient name: RogerVerified: NOHISTORYPresenting for: Roger presented for ear infection, eye infection, and skin irritation with pruritusHistorical Conditions: Previous episodes of similar allergic processes affecting ears, eyes, and skin that resolved but recurredDiet: Science Diet dry food, occasional dog treats from cheap shopSkin: Recurrent skin problems described as hairspring being more oily, pruritic episodes with scratching at groin area and underneath, crusting around eyes that becomes black and crusty, chewing at feetCurrent Meds: Previously used medicated shampoo at groomer but formulation changedLifestyle Risk Factors: Lives in Lake Ridge area, regular grooming at parlourEXAMBehavioural: Cooperative and easy to handle for ear and eye medications, accepts tablets readily, good temperament during examination proceduresEyes: Conjunctivitis present bilaterally with black crusty discharge around periocular area, eyes themselves appear healthyEars: Erythema and discharge present bilaterally, patient comfortable with ear examination and medication administrationIntegumentary: Crusting lesions around eyes and ears, pruritic dermatitis affecting groin and ventral areas, patient observed scratching and chewing at feetDiagnostics: Schirmer tear test performed bilaterally - left eye reached 15mm in 15 seconds, right eye reached 50mm, both within normal limits. Skin cytology revealed bacteria and Malassezia. Ear cytology showed mixed infection with bacteria and MalasseziaASSESSMENTAllergic dermatitis with secondary bacterial and Malassezia infections - Affecting skin, ears, and eyes with recurrent nature suggesting underlying allergic process. Potential causes discussed include flea allergies (less likely due to effective flea control), food allergies, or environmental allergies given Lake Ridge location. Secondary infections confirmed on cytology requiring antimicrobial therapyASSESSMENTAllergic dermatitis with secondary bacterial and Malassezia infections - Affecting skin, ears, and eyes with recurrent nature suggesting underlying allergic process. Potential causes discussed include flea allergies (less likely due to effective flea control), food allergies, or environmental allergies given Lake Ridge location. Secondary infections confirmed on cytology requiring antimicrobial therapyPLANNew Meds/Tx:- Anti-pruritic medication for allergic process - one tablet SID for itch relief- Antifungal capsules for Malassezia infection - one capsule SID  - Antibiotics for bacterial infection - one tablet BID- Ear drops - administer 0.6ml in both ears BID for 10 days using provided syringes- Eye ointment - apply to both eyes as directedAdditional Discussion:- Recheck appointment scheduled for 18th at 08:40- Discussed potential for referral to dermatologist for allergy testing if owner wishes to determine specific allergens- Explained that treatment addresses current infections but may not prevent recurrence if underlying allergies not managed- Warm water compresses recommended to help dissolve crusts around eyesClient Comms:- Text message confirmation will be sent for recheck appointment- Patient should show significant improvement with current treatment plan- Underlying allergic condition may require ongoing management to prevent recurrence    Vital Signs    Weight: 9.5 (Patient Update);