C09995468 / invoice 10000

Appointment Reason: 1.3 CONSULT 3, Appointment Notes: day 10 post op check + ear infection  RS  ------- Sms reply: YVet: ASBPresenting Concern: Post-castration recheck and new onset of ear irritation.HISTORY:-   Oakley is presented for a post-castration recheck and for investigation of a new issue of scratching at his ears.-   The O reports the surgical site appears to be healing well, however, Oakley will lick the area if the e-collar is removed. He is no longer showing signs of discomfort (e.g., frequent sitting).-   There is a history of allergies, with a suspected trigger being chicken. The O notes he may have recently ingested some puppy food containing chicken.-   There is a history of previous ear infections.  EDDU: Normal  V/D/C/S: No V+ or D+. No coughing or sneezing.  Vaccination Status: Not discussed  Current Medications: None  Additional Information:-   The O uses an ear cleaner after swimming to help dry the ears.-   Oakley has previously been on an exclusion diet (venison) which was successful. Kangaroo was also tolerated, but lamb was not.CLINICAL EXAMINATION:Demeanor: Anxious but responsive  Temp: not taken, HR: WNL, RR: WNL, MM & CRT: Did not examine due to behaviours. BCS: 4/9  Hydration: No evidence of dehydration  Nasal: No nasal discharges.  Eyes: Clear, equal in size, no discharges. Normal vision.  Ears: Bilateral otitis externa noted. Erythema bilaterally. Mild brown discharg bilaterally.  Dentition/Oral: Did not examine due to behaviourCardiovascular: Normal rhythm, no murmurs/arrhythmias auscultated. Pulses strong and synchronous  Respiratory: Normal bronchovesicular sounds, no adventitious lung sounds, no increase in effort.  Lymphatics: Palpable lymph nodes WNL.  Skin: No abnormalities noted.  Abdomen: Did not palpate due to behaviourMSK: Ambulatory. Good muscle definition, no evidence of muscle atrophy or peripheral joint pain.  Urogenital: Post-castration surgical site is healing well with no signs of infection or significant inflammation.  Neuro: Normal gait, proprioception and mentation, full neurological exam not performed.  Rectal: not performedDIAGNOSTICSDiagnostics:  Ear Cytology:  Right Ear: Malassezia ++  Left Ear: Malassezia ++ASSESSMENT:-   Bilateral Malassezia otitis externa-   Post-castration recheck - healing wellTREATMENT/ PROCEDURES:Dispensed:-   PMP ear drops 20ml bottle x 1. Apply 0.5ml into each ear BID for 10 days.CLIENT COMMUNICATION/ PLAN:-   A recheck appointment is recommended in 2 weeks to re-swab the ears and ensure the infection has resolved.-   The e-collar can now be removed. Advised to monitor for obsessive licking of the surgical site and replace the collar if this occurs.-   Discussed potential underlying causes for recurrent otitis, including food allergies and the e-collar potentially trapping moisture.-   Advised to continue the current diet of venison and/or kangaroo and to avoid known triggers like chicken and lamb.-   If ear infections recur despite treatment and regular cleaning, future management options could include topical steroid drops to manage inflammation.Notes written by AI and edited by ASB    Vital Signs