C09988923 / invoice 10000

04/03/2026 Primary Presenting Complaint - scratching at ears 
Other Complaint - otherwise well 
         Loyalty Reward Program - Y/N
History - 
         Last Normal - noticed 4 days ago 
         Frequency   - shaking head, scratching, mostly left 
         Last Ate       - today 
         Medicine Hx  - none 
         Diet              - biscuits 
         Vacc Current - UTD 
         Worming Hx  - UTD 
         Heartworm    -
         Microchip       -  Y / N    -  scanned - ok?

Examination -
         Attitude - BAR very friendly boisterous 
         Body Score -    8/10
         Temperature - not taken 
         Heart - 96  HR. Murmur - non heard 
         RR - panting 
         Dental - Score(0-4)=   1  .Comment mild dental disease 
         CRT - immediate
         Eyes - NVL
         Ears - cerumetous discharge from both ears left pinna thickened cytology revealed mild malassezia infection 5-7/hpf 
         Abd Palpation - Unremarkable
         Gastrointestinal -  No Sig Findings
         Urogenital -  No Sig Findings
         Skin - some redness in between toes 
         Musculoskeletal -  No Sig Findings
         Neurological -  No Sig Findings
         Lymphatic - No Sig Findings
         Other key findings = 

Assessment - 
Problem List - otitis externa 
DDx                 - yeast infection secondary to allergic skin disease environmental allergies vs food allergies vs atopy 
Discussed      - not really had an issue with ears before but if recurrs can think about treating with long term allergy treatment eg cytopoint or apoquel 
Treatment Plan - novasone to reduce inflammation 
Prescriptions(on-going) -
Next Visit            as needed