C09986567 / invoice 10000

04/03/2026 
HISTORY: The pet has been treated with steroids and an ear flush for ear issues. The ears have improved, becoming softer and not causing discomfort. The pet is also being treated with steroids for foot licking, suggesting possible skin irritation or allergies.

CLINICAL EXAM:
Demeanor: BAR
Ears: Previously inflamed, currently improved with treatment
Eyes: NAD - clear
Nose: NAD - no discharge or changes
Oral cavity: mm- pink & moist
Lymph Nodes: NAD
Cardio-respiratory: heart sounds regular, lungs clear
Abdomen: NAD - no pain or abnormalities on palpation
Skin: Treatment ongoing for foot licking
Musculoskeletal: gait normal
BCS: 
Temp: 

Ddx: Otitis externa, dermatitis

ASSESSMENTS: Ear cytology - significant improvement noted, fewer inflammatory cells compared to previous tests

TREATMENTS OPTIONS:
- Continue use of steroids and ear flush as prescribed

PLAN:
- Continue current treatment for ears and foot licking
- Recheck at next scheduled visit for immunizations
- Monitor for any recurrence of ear discomfort or skin irritation