C09986646 / invoice 10000

Reason: Ear Infection KmAppointment Notes: Owner has put coconut oil onit and it has not worked it still looks red and her is hanging his head to one side.HISTORYPresenting for: Spencer presented for a 2-3 day history of excessive head shaking and ear scratching, with head tilting to the left side noticed yesterday.Historical Conditions: Hypothyroidism currently on thyroid medication. Previous skin issues secondary to hypothyroidism, treated with antibiotics by Dr Duncan and resolved. Drinking/Urination: Increased water consumption due to thyroid medicationSkin: Previous skin issues , resolved following antibiotic treatment and topical coconut oil applicationCurrent Meds: Thyroid medication (dispensed from clinic 2 weeks ago)Lifestyle Risk Factors: Recent walks to river areas over the weekend, no swimming or rolling reportedOther: Owner applied coconut oil to ear edges yesterday due to perceived irritation. Patient more active and losing weight since starting thyroid treatment.EXAMBehavioural: Cooperative during examination, readily accepted liver treats from veterinary staffEars: Left ear - moderate discharge present, erythema noted. Right ear - minimal abnormalities visible on otoscopic examination. Patient demonstrated head shaking and left head tilt during examination.Neurologic: Head tilt to the left side observedDiagnostics: Bilateral ear cytology performed - Left ear: mixed Malassezia and cocci bacteria infection. Right ear: Malassezia infection present, no bacteria detected.ASSESSMENTBilateral otitis externa - Mixed yeast and bacterial infection, left ear more severely affected than rightPLANNew Meds/Tx:- Dermotic ear drops 5 drops each ear BID for 2 weeks - contains antifungal, antibiotic and corticosteroid componentsAdditional Discussion:- Recheck ear cytology recommended at completion of treatment course- Patient due for thyroid recheck blood test - can schedule concurrent with ear recheck appointment    Vital Signs    Weight: 45.9;