C09988953 / invoice 10000

Reason: SS - Ear RV (Keep Extended) TM Appointment Notes: Overdue remindersReason:(Assisted by: )HISTORY:  Recheck consultation for pruritus and yeast otitis externa of the left ear. The owner reports continued head shaking but less than previously, with the last dose of steroid tablet administered on Sunday, 01/03/2026. There is a history of a moderate yeast infection in the ear. The owner recalls a previous monthly Cytopoint injection was effective in controlling the pruritus. The pruritus is localised to the ear mostly. Current meds: Recently completed a course of steroids.Vaccination: Not mentionedParasite Prevention: nonePre-existing conditions: noneAccess to toxins eg. Rodenticide: none EXAMINATION:Body Condition Score: 6/9Pain Scale (0-4): 0/4Hydration status (%): hydration clinically adequateMusculoskeletal: ambulating normally, no observable neck, spine, limb or joint painGastrointestinal:Oral: normal, no mouth painAbdominal: not performedRectal: not performedUrinary: NSFReproductive: NSFIntegument/Ears: Left ear mildly inflamed, mild-moderate dark waxy material on sample collection. Cytology of the left ear was performed.Lymph Nodes: NSFEyes: NSFDemeanour/Behaviour: BAR, compliant on exam but apprehensive of swab obtained from left ear PROBLEM LIST:Chronic/recurrent pruritus of the left ear.Suspected underlying atopy. DIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:Atopic dermatitis. DIAGNOSTICS:Ear cytology (left ear): No yeast or bacteria seen. The previous infection has resolved. ASSESSMENT:Recheck for a pruritic ear. Examination and cytology confirm the previous yeast infection has resolved. The persistent pruritus despite steroid treatment suggests an underlying allergic component, supported by a history of a positive response to a previous allergy injection. The localised pruritus is likely due to compromised skin integrity in the ear from previous infections. TREATMENT:  Cytopoint 40mg injection administered SQ between shoulder blades, to manage allergic pruritus. (Batch #845661) PLAN:Monitor response to Cytopoint injection.If pruritus persists or the condition recurs frequently, referral to a veterinary dermatologist is recommended to investigate options for improving the long-term health of the ear canal skin.Home into owner's care. CLIENT COMMUNICATION:Discussed that the ear infection has cleared, but the underlying cause of the itch is likely an allergy. Explained that the Cytopoint injection is intended to control this allergic itch. Advised that if signs do not improve, a referral to a specialist dermatologist would be the next step to manage the chronic changes in the ear. The owner understands and has consented to the plan.    Vital Signs    Weight: 38;