C09995701 / invoice 10000

Appointment Reason: 2 IN WAITING ROOM, Appointment Notes: Recheck ears,  O bringing in swabs from home rbk  ------- Sms reply: YHISTORYATTENDING VET: Dr Rachel Bush-King, BVSc (Hons) GPCertSAM  Presenting Concerns:-   Leo presented for a recheck of otitis externa, which was diagnosed approximately 9 days ago.  Current Medications:-   The patient recently completed a 7-day course of PMP ointment, with 1 mL administered into AU BID.-   A course of prednisolone was also administered and has been completed.  Additional Information:-   The O reports that Leo's ears are significantly better and appear less red, now having a more normal pinkish color.-   Head shaking has reportedly settled; the O notes he now only shakes his head in the morning upon waking.-   The O has not observed any scratching.-   The O has been using an ear cleaner they already had at home and has noticed less discharge.-   The O also mentioned that the skin on his groin is a lot better.PHYSICAL EXAM-   Ears: Externally, the ears appear improved. The L Ear, which was previously more erythematous, now appears less inflamed than the R Ear. Otoscopic eam deferred similar to last visit.-   Integumentary: The skin on the groin has improved. It was previously hyperpigmented and is now returning to a normal pink color. This is suspected to be resolution of post-inflammatory changes, potentially aided by the recent course of steroids.  Diagnostics:-   Ear Cytology (O-collected swabs): Sporadic Malassezia organisms were identified in samples from AU. This is a marked improvement from the previous cytology which showed 3+ Malassezia. The sample from the L Ear contained fewer organisms than the right.ASSESSMENTProblem List1.  Otitis Externa (Malassezia) - There has been a significant clinical and cytological improvement following a 7-day course of PMP ear ointment and oral prednisolone. However, a persistent low-grade Malassezia infection remains in AU.2.  Inguinal Hyperpigmentation - Resolved. This was assessed as likely post-inflammatory hyperpigmentation, which has settled with time and the anti-inflammatory effects of the prednisolone treatment.PLANClient Communication:-   Discussed the cytology results with the O, explaining that while there is significant improvement, a low number of yeast organisms are still present, necessitating an extension of treatment.  Medications/Treatments:-   Dispensed additional PMP ointment.-   Instructions: Continue to administer 1 mL into AU BID for another week.-   A recommendation for a gentler ear cleaner (Paw Gentle Ear Cleaner) was sent via text message, but the O was advised it is acceptable to continue using their current product.-   Provided the O with swabs to collect samples at home for the next recheck.  Ongoing Plan:-   A recheck appointment is scheduled for 1 week.-   The O will collect ear swabs at home prior to the appointment for follow-up cytology to ensure complete resolution of the infection.  This document was generated with the assistance of CoVet AI to support accurate and efficient documentation.    Reviewed by: RBK    Vital Signs