KOALA — Koality Assurance for diagnosis prediction models

Consult notes

PRESENTING/OWNERS CHIEF COMPLAINT/REASON FOR VISIT: (C5 and check ears)

Consult Nurse: (MH)

History
EDDU: Normal
Vomiting/Diarrhea: No V+ or D+
Diet: Royal Canin Lightweight food. Also receives Greenies and Oravet chews.
Vaccinations: Due for annual update.
Preventatives:
- Worming: Nexgard Spectra, administered monthly.
- Heartworm: Nexgard Spectra, administered monthly.
- Flea & Tick: Nexgard Spectra, administered monthly.
Current Age: 8y 2m
Current Medications: Otoflush is used weekly for maintenance, and twice daily during flare-ups of ear redness.
Behaviour Concerns:
History: The owner reports recurrent redness in the ears over the last 2-3 weeks. She describes it as a "losing battle"; she flushes the ears twice daily when red which resolves the issue, but upon reducing the frequency to once daily, the redness returns. Arlo is not shaking his head much but was observed rubbing his ear on the ground yesterday. He has a history of being prone to ear infections and is groomed monthly. He has successfully lost weight, going from 35 kg in April of the previous year to a current weight of 31.6 kg.

Physical Exam
General Appearance: BAR
Behaviour: friendly but stand-offish
Vitals: Weight: 31.6 kg
Hydration: normal
BCS: 5/9
EENT: eyes clear, no evidence of conjunctivitis, no discharge or blephrospasm; Erythema noted in the external ear canals bilaterally with mild light colored ceruminous debris. no nasal discharge; mild tartar
Cardiac: normal rate and rhythm, no murmurs on auscultation
Resp: normal rate, normal clear sounds auscultated in all lung fields
Abdo: comfortable on abdominal palpation, no palpable abnormalities
Urogenital: neutered
Integument: no external parasites noted; no erythema or pruritis
Neuro: proprioception NAD; NSF
Musculoskeletal: ROM in all joints NAD; no abnormalities on palpation
Lymph Nodes: Peripheral LN's WNL

Client Communication from Consult Nurse
No communication recorded.

Client Communication with Vet
A detailed discussion was had regarding Arlo's history of recurrent otitis, his current diet, and preventative care. His successful weight loss was praised. A plan to perform ear cytology was recommended to identify the infectious agent. An estimate was provided and approved by the owner, totalling $229.92 for the consultation, discounted vaccination, and ear cytology, with medication costs being additional. Following the cytology, it was explained to the owner that the infection was bacterial, with a predominance of rod bacteria, necessitating a specific antibiotic ear drop.

Laboratory/Imaging
Ear Cytology: Samples were collected from both ears. Microscopic examination revealed a bacterial infection with a predominance of rod-shaped bacteria. AS - 3+ rod, 1+ cocci, AD 2+ rod, 1+ cocci

Assessment/Problem list
- Bilateral bacterial otitis externa (rod-predominant)
- For annual vaccination
- Ongoing weight management

Treatment
Medications: Easotic ear suspension, 1 pump administered into each ear once daily for 5 days.
Vaccinations: Annual vaccinations administered.

Plan
- Administer Easotic as prescribed for 5 days.
- Schedule a recheck appointment in 1 week for repeat ear cytology to confirm resolution of the infection.
- Continue with the current weight management plan.

(GHC in 6mths)

Internal treatment plan Comms

Follow up notes
Recheck visit scheduled in 7 days for repeat ear cytology.
Follow up phone call for: Not specified.

Animal clinical history (3 most recent)

2026-03-04T00:00:00Z 09:00:00