C09985150 / invoice 10000

Reason: Head Tilt - Ear Infection ?Appointment Notes: Overdue remindersHISTORY:Monty presented for assessment of his ears. The owner noticed discharge a few days ago and cleaned the ears with Epi-Otic. Last night, Monty was panting throughout the night and is holding his right ear lower today, which the owner suspects is due to an ear infection. A history of panting at night is associated with ear pain. The owner also reports an onset of car sickness over the last few days. Monty has a history of recurrent ear infections. There is a small lump on his right side that was previously assessed by his specialist veterinarian, Dr Emily Cook, who advised monitoring.No head tilt noted today Current meds: Epi-Otic ear cleaner used two days ago and last night.Pre-existing conditions: Recurrent otitis externa.Access to toxins eg. Rodenticide: noneEXAMINATION:Hydration status (%): hydration clinically adequateCardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: neurologically no significant findingsMusculoskeletal: ambulating normally, no palpable neck, spine, limb or joint painGastrointestinal:- Oral: 1- Abdominal: no detectable pain on abdominal palpation, no palpable organomegaly or mass lesions noted- Rectal: Not performedUrinary: NSFReproductive: NSFIntegument/Ears: Both ear canals appear erythematous. A dark-coloured discharge was noted from the right ear canal. A small, palpable subcutaneous mass consistent with a sebaceous cyst is present on the right flank.LABORATORY:An ear swab was taken from both ears for cytology. Microscopy confirmed the presence of an ear infection, more severe in the right ear but present bilaterally. Cocci ++ASSESSMENT:The clinical signs and cytology results are consistent with bilateral otitis externa, which is more severe in the right ear. The subcutaneous mass on the right flank is suspected to be a sebaceous cyst and is not of immediate concern.TREATMENT:Treatment for bilateral otitis externa was prescribed. The owner was instructed to administer Dermotic 0.7 mL into each ear twice daily for seven days.PLAN:A recheck consultation has been scheduled in 10 days, on 14/03/2026 at 8:30 am. This will involve a re-examination, repeat ear swabs to confirm resolution of the infection, and assessment of the lump.Home into owner's care.    Vital Signs    Weight: 10.7;