C09989990 / invoice 10000

27/02/2026 HISTORY
Presenting for: Rusty presented for ear infection with no improvement following previous treatment 2.5 weeks ago. Ear flush at local vet -  Left ear was worse than right. Long acting ear gel was instilled.  Owner noticed discharge a few days after initial treatment. Very difficult to examine ears and administer ear drops. Occasional licking of feet.

Historical Conditions: Recurrent ear infections. Hydrocephalus diagnosed when younger following behavioural changes (seemed vacant at times) - had brain surgery with shunt placement, clinically normal now.
Current Meds: Owner has Trazodone and Gabapentin for pre-visit anxiety, Prednisolone 20mg tablets at home. Previously using Elocon weekly but discontinued due to difficulty administering ear drops.


EXAM
Mentation: BAR, friendly but hates ears examines - thrashing around and distressed . 
BCS: 5/9
HR: 88
RR: panting
MM: pink
Hydration: good
Eyes: nad
Ears: Right ear - small amount of brown discharge along canal with plug at base of canal. Left ear - extremely painful, copious moist discharge, unable to examine properly due to pain
Oral: Grade 2-3 dental disease
:Abdominal: soft and comfortable
Lymph Nodes: wnl
Integumentary: Feet - no erythema
Musculoskeletal: nad

Diagnostics: Cytology right ear - Malassezia +. Cytology left ear - neutrophilic streaming +++, Malassezia ++, cocci ++

ASSESSMENT
Bilateral otitis externa - Mixed bacterial and yeast infection based on cytology, left ear more severely affected with significant inflammation

PLAN
New Meds/Tx:
- Prednisolone 30mg SID for 5 days to reduce inflammation and pain, 20mg 4 days, 10mg sid 4 days
- Trazodone 300mg and Gabapentin 600mg evening before and morning of next visit for anxiety management
- Compounded paloxamer ear drops containing Enrofloxacin, Ketoconazole, and triamcinolone ordered for instillation at time of ear cleaning
Additional Discussion:
- Repeat ear flush recommended due to amount of discharge, owner not keen and prefers home treatment initially
- May not be able to clean ear at next visit if still too painful/anxious, would require another ear flush under sedation
- Dental treatment recommended
- Raw meaty bones recommended for dental health
Client Comms:
- Unable to clean ears today due to pain level
- Will attempt ear cleaning at next visit with pre-medication
- If unsuccessful, will need ear flush under sedation

05/03/2026 o gave 300mg traz and 600mg gaba last night and this morning
very sleepy 
had pred 30mg 5 days and 20mg past 2 days 
doesn't seem bothered by ear 

hesitated initially but managed to clean both ears with epiotic - R ear small amount discharge at base afrecter clean. large amount brow discharge removed R ear - canal quite clean afterwards, no erythema. unable to visualise tympanic membranes
instill 1.5ml ploxamer both ears 
O to try instill next week with gaba/traz - is unable will call me to instill 
recheck 3 weeks - recommend 300mg traz and 900mg gaba evening before and morning of appt
continue pred 20mg sid for 2 days then 10mg for 4 days