C09989637 / invoice 10000

Reason: Recehck Ears CCEMAppointment Notes: rescheduled from 3/3 due to owner being unwell. Original appt booked by clinic for 20 min. CCEM  ------- Sms reply: YOn way few mins away - Bentley had to stop and do a poop. advised may need to change appt as running late CCKMHISTORY:Bentley presented for follow-up of right ear infection previously treated with dermatological ear drops prescribed by Dr Sandy. Owner reports ear drops were well tolerated, though required two people to administer. Previously received Cytopoint injection for pruritic skin condition with redness and nipple changes. Owner reports skin condition has resolved. No new areas of scratching or pruritus noted. Right ear no longer being scratched. Left ear showing early signs of inflammation.Regular Vet diagnostics and treatments: Dermatological ear drops for right ear infection, Cytopoint injection for allergic dermatitisEDUD wellno CSVDCurrent meds: noneVaccination: Not mentionedParasite Prevention: Not mentioned  Pre-existing conditions: Recurrent ear infections, allergic dermatitisAccess to toxins eg. Rodenticide: noneCurrent diet: no changeEXAMINATION:Body Condition Score: 5/9Pain Scale (0-4): 0/4Hydration status (%): hydration clinically adequateCardiovascular: HR normal, normal rhythm, no murmur detected. Pulses normal and synchronousRespiratory: thoracic auscultation clear sounds bilaterally no crackles, RE normal, no nasal dischargeNeurological: neurologically no significant findingsMusculoskeletal: ambulating normally on all 4, no stiffness, no palpable neck, spine, limb or joint painGastrointestinal:- Oral: normal, no mouth pain, dental score (1-4): not graded- Abdominal: soft and comfortable, no palpable masses, no detectable pain on abdominal palpation- Rectal: not performedUrinary: NSFReproductive: NSFIntegument/Ears: Right ear improved, left ear showing early inflammatory changesLymph Nodes: smooth small symmetricalEyes: NSFDemeanour/Behaviour: Anxious during examination, required restraint for ear examinationPROBLEM LIST:Resolved right ear infectionEarly left ear inflammationHistory of allergic dermatitis - currently controlledDIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:Otitis externa - right ear resolving, left ear early changesAllergic dermatitis - controlled with CytopointDIAGNOSTICS:Ear cytology performed on both earsRight ear: Cell debris present due to previous inflammation, no active infectionLeft ear: No significant abnormalities detectedASSESSMENT:Right ear infection has cleared following treatment. Left ear showing early inflammatory changes but cytology negative for infection. Previous allergic dermatitis well controlled with Cytopoint injection. Behavioural issues noted during examination requiring desensitisation training.TREATMENT:No medications required todayFur trimming around ears recommended to improve airflowPLAN:Monitor left ear for progressionContinue ear hygiene and airflow managementAvoid water contact around head areaAdvise groomer to avoid ear areaConsider diet trial if allergic dermatitis recursDesensitisation training for ear handling at home with positive reinforcementCLIENT COMMUNICATION:Owner advised ear infection has cleared and left ear currently shows no active infection. Discussed importance of keeping ears dry and maintaining good airflow. Recommended desensitisation training at home for ear handling using treats and positive reinforcement. Advised to monitor for return of skin allergies and contact if symptoms recur. If allergic dermatitis returns, may need to discuss diet trial versus ongoing Cytopoint management.    Vital Signs    Weight: 30;