C09985271 / invoice 10000

Reason: Ear / Infection / Cytopoint / Nail Clip / Eye infeAppointment Notes: Booked Online: 04/03/2026 06:18:29 AMBooking Type: Skin, Ears, Eyes or LumpsBooking Notes: ear infection Eye infection Cytopoint nail Nail Clip Owner Name: Jessica KuschOwner Email: jessicakusch11@gmail.comOwner Mobile Number: 0490055114Pet Name: sadiePet Species: DogWeb BookingClient name: KuschContact number: 0490055114Email address: jessicakusch11@gmail.comPatient name: sadieReason: Name of Client Present:TBC Nurse Initials:Client Concerns: ear infection, has had elocon in the past this worked, nail clip + cytopoint. Had higher dose of cytopoint with dr james would lik this again if applicable - check skin on stomach as red dots has been seen by dr james before for this and he said was fine + tapewormer - if can give today in consult wound prefer if nto happy to go home with it. Vaccination: (Type:core     ) (Last Given: 10/25  )Parasite Prevention: (Product Name: nexgard spectra  ) (Last Given:  3 weeks   )Microchip # & Behaviour Indicator filled in: no Insurance / Healthy Pets Plus: gap claim  + HPP Is patient on any medication? No Current Diet:Product: delicate care fish rice skin stomach Feeding schedule:Laboratory Testing Needed:_____________________________________________________________**History:**Presenting complaint: Right ear issue, recurrent problem. Owner unsure of duration. Generalised pruritus, particularly licking paws.Pertinent medical hx: Atopic dermatitis, managed with Cytopoint injections every 1-2 months. History of intermittent diarrhoea.Current medications: Cytopoint 30mg SC every 1-2 months. Received a double dose (30mg) at the last visit which seemed more effective.Current diet: Kibble, owner is strict with diet but patient occasionally gets other food.History of recurrent right-sided otitis externa. Generally pruritic, especially licking paws. Episode of diarrhoea two weeks ago, which is a common occurrence, resolved. Not on any special shampoos, uses an over-the-counter product. DUDE normal. **Examination:**Mentation: Bright, alert, responsiveTemperature: NTHeart Rate: 108Respiratory Rate: 28Mucous Membrane: Pink, moist, CRT: <2sCardiovascular: No murmur or arrhythmia detected. Femoral pulses normokinetic, synchronous.Respiratory: Normal bronchovesicular sounds right and left lung fields.Body condition score: BCS 5/9Abdominal palpation: Soft and comfortable abdomen throughout.Oral examination: No obvious abnormalities detected.Ocular examination: Pupillary light reflexes present and consensual, normal menace responses and palpebral reflexes.Aural examination: Left ear canal clear, TM intact. Right ear has a moderate amount of dark, waxy discharge in the external canal and on the pinna, with mild erythema of the canal. No foreign body visualised in either ear. Both tympanic membranes are intact.Integument: mild interdigital erythema all4, mostly LF. Lymph nodes: Submandibular, pre-scapular and popliteal lymph nodes normal size.Urogenital examination: No obvious abnormalities detected.Rectal exam: Not performed.Neurological examination: Normal mentation, ambulatory with voluntary movement in all limbs and tail. Full neuro exam not completedMusculoskeletal: Ambulatory, able to rise and ambulate without difficulty. Normal gait.**Problem List:**1. Otitis externa (right ear)2. Pruritus (paws)3. Mild yeast and suspect cocci bacteria on ear cytology (right ear)4. History of atopy**Differential Diagnosis:**Otitis externa: secondary to underlying atopy, bacterial infection (cocci), yeast overgrowth (Malassezia), foreign body (ruled out on otoscopy), parasitic (mites - less likely).**Diagnostics:**Ear swab cytology (in-house):Right ear: Mild numbers of yeast (4-5/hpf in some fields), small clusters of suspect cocci bacteria vs debris.Left ear: Minimal yeast (1-2/hpf).**Assessment:**Right otitis externa, likely a mixed infection of yeast and bacteria secondary to underlying allergic skin disease. The pruritus and paw licking are consistent with atopic dermatitis. Ear infections are likely an extension of the skin inflammation. Left ear appears clinically and cytologically insignificant.Client Communication:Discussed examination and cytology findings with the owner. Explained that the ear infection is likely a combination of yeast and bacteria, secondary to underlying allergies. Discussed treatment plan including ear drops, a Cytopoint injection, medicated shampoo for paws, and a topical steroid for paws. Explained the rationale for using medicated shampoo and topical steroids for managing skin inflammation between Cytopoint injections. Advised on how to use the medications, including frequency and duration. Counselled on the need to wear gloves when handling the topical steroid, and not to handle if pregnant. Plan for a recheck in one week to assess the ear.**Treatment:**Cytopoint 30mg given SC dorsal shoulders in clinic.virbac tapewormer given PO in clinic.Easotic ear drops: Apply to the right ear once daily for one week.Novasone (mometasone) cream: Apply topically to paws once weekly for maintenance of inflammation.Malaseb shampoo: Recommended for use on paws and other itchy areas once to twice a month. Leave on for 10 minutes before rinsing. Advised can be purchased over the counter.**Plan:**Recheck consultation in one week to re-evaluate the right ear.Continue home care with Eotic, Novasone and Malaseb as directed.A plan for preventative intermittent use of topical steroids in the ear will be made at the recheck appointment if the infection has resolved.Continue Cytopoint injections as needed for management of atopy..    Vital Signs    Weight: 16.5;