C09994612 / invoice 10000

Reason: Possible Right Ear InfectionAppointment Notes: Overdue remindersHISTORY:  Presented for assessment of right ear. Owner noticed redness and pinkness of the pinna 3-5/7 days ago. Occasional head shaking and scratching at the ear. History of dermatitis, currently managed with a medicated shampoo. No recent swimming (last swam 1/12 mo ago).Current meds: Malaseb shampoo every other day.Parasite Prevention: NexGard Spectra monthly. UTD.Pre-existing conditions: Dermatitis.Access to toxins eg. Rodenticide: none EXAMINATION:Body Condition Score: 5/9Integument/Ears: Right pinna erythematous. Skin on abdomen NAD. Otoscopy revealed right ear canal not significantly inflamed, minimal discharge. Left ear NAD.Demeanour/Behaviour: BAR  DIAGNOSTICS:Ear cytology performed.- Left ear: NAD- Right ear: Yeast organisms present. ASSESSMENT:Ear cytology confirmed a yeast infection in the right ear. Concurrent dermatitis is being managed with medicated shampoo. TREATMENT:  - PMP ear drops: apply 1ml to right ear BID for 14 days. Showed O how to do it today. - Malaseb shampoo: continue use as directed for dermatitis.- Otoflush ear cleaner: dispensed but use deferred until after treatment course. PLAN:Re-check consultation in 15 days for repeat ear cytology to confirm resolution of infection.Home into owner's care. CLIENT COMMUNICATION:Discussed diagnosis of yeast otitis externa. Demonstrated application of PMP ear drops. Advised to continue treatment for full 14/7 course. Instructed to book re-check appointment for day 15. Advised to avoid swimming during treatment. If accidental water exposure occurs, clean ear with Otoflush and ensure it is dry. Dispensed Malaseb shampoo and Otoflush. Advised to hold off using Otoflush until after the course of ear drops is complete. Client understands and agrees with the plan.    Vital Signs    Weight: 27.2;