C09987474 / invoice 10000

Appointment Notes: Ear infection R worse then leftHISTORYCLINICAL EXAMINATIONBar VinDDX/PROBLEM LISTTRT?????Subjective:History: Cookie presented for assessment of her ears. The owner reports she has been shaking her head and scratching at her ears. This is a recurrence of a similar issue from seven months prior, which responded well to oral corticosteroid/antihistamine tablets. The owner has an ear cleaner at home but has not been using it recently. She is otherwise reported as being healthy. Toileting behaviour is normal. The owner notes she sometimes chews her feet and frequently rolls in grass.- Clinical signs/progression: Acute onset head shaking and ear scratching.- Significant history: Recurrent otitis/dermatitis, previous episode seven months ago.- Current medications: Neocort ointment at home. Ear cleaner at home, not in use.- Appetite & diet: Appetite and thirst are normal.Objective:Vital Signs:- Blood Pressure: Not mentioned.- Heart Rate: 135 bpm- Respiratory Rate: Panting- Temperature: 38.7°CDemeanour: Bright, alert, and responsive. Friendly and cooperative during examination.Examination Findings:- Eyes: No abnormalities.- Ears: Bilateral mild pinnal and external ear canal erythema. Minimal exudate present. Sensitive on examination.- Oral: Moderate periodontal disease with mild dental plaque.- Nose: Not mentioned.- Peripheral lymph nodes: No abnormalities.- Cardiovascular: No abnormalities detected on auscultation.- Respiratory, breathing: Lungs clear on auscultation. Panting throughout consult.- Urinary/Genital: Not mentioned.- Skin: Erythema of paws. Mild ventral abdominal erythema.- Abdomen: Not mentioned.- Rectal examination: Not mentioned.- Neurological: Not mentioned.- Musculoskeletal: Not mentioned.- BCS: 5/9- Hydration: Adequate.- Other Findings: Ear and foot cytology revealed significant inflammatory changes without evidence of bacterial or yeast infection.Problem List:1. Allergic otitis externa and pododermatitis.2. Moderate periodontal disease (incidental finding).Assessment:Cookie presents with an acute flare-up of allergic skin disease, manifesting as bilateral otitis externa and pododermatitis. Cytology confirms inflammation is the primary issue, with no secondary infection currently present. The clinical signs are consistent with a recurrence of a previously diagnosed condition, likely atopic dermatitis. Moderate periodontal disease was noted as an incidental finding requiring future management.Plan:Treatment Plan:1. Nirone tablets: Administer 1/2 tablet orally twice daily for 3-5 days, then 1/2 tablet once daily for 5 days, then 1/2 tablet every second day.2. Topical treatment: Apply owner's Neocort ointment to erythematous paws as needed.3. Environmental management: Advised to wipe Cookie's paws and ears with a damp cloth and dry thoroughly after being on grass to reduce allergen contact.Progress Notes: Initial consultation for this episode.Client Communications: Discussed diagnosis of allergic dermatitis. Explained treatment plan using oral Nirone to control inflammation and itch. Advised on home care including topical ointment and allergen avoidance. Prognosis for controlling the current flare-up is good. A preventative anti-inflammatory ear ointment ($85) was offered for long-term management but was declined at this time. Advised to monitor for worsening signs (discharge, pain) and to return if concerned.Allergies: None known.Additional:- Prognosis: Good for control of the current inflammatory flare-up.- Treatment Declinations: Owner declined purchase of preventative anti-inflammatory ear ointment today.?????    Vital Signs    Weight: 9.3;