C09997114 / invoice 10000

06/03/2026 Consultation nurse: FB

REASON:
Recheck ears.

HISTORY:
Presented for a recheck of yeast otitis externa in the left ear. Owner reports Odie is generally well, eating and drinking normally, though has been much thirstier. There is still some discharge present in the ear, but it is unclear if this is residual or an ongoing issue. The condition has improved but is not completely resolved. Previously, owner had difficulty medicating due to biting, but this improved with trazodone and a muzzle.

Current diet/change in intake:
Normal appetite. Increased thirst.

Owner concerns:
Ongoing anxiety. Licks and chews at his left forelimb, causing self-trauma. Generally on edge, will snarl if approached too closely but has no history of biting. Sensitive to sudden movements.

Previous medical/surgery history:
Yeast otitis externa (left ear).

Current meds:
Prednisolone 20mg, half a tablet every second day.

RECORD VITAL SIGNS:

EXAMINATION:
Demeanour- Anxious but manageable.
Ears - Otoscopy performed on the left ear. Significant discharge present, however, the ear canal appears clear down to the tympanic membrane.

DIAGNOSTICS:
Ear cytology (left ear): No organisms seen on microscopy.

ASSESSMENT & TREATMENT

1. Otitis Externa (Left Ear)
- Assessment: Resolution of yeast infection. Residual discharge is likely secondary to medication. No foreign body visualised.
- Treatment plan: Continue to monitor.

2. Anxiety and Compulsive Behaviour
- Assessment: Long-standing history of anxiety manifesting as hypervigilance, reactivity, and self-trauma (licking/chewing left forelimb).
- Treatment plan: Discussed initiating anxiolytic medication.
- - Commencing a trial of fluoxetine. Script provided for owner to source from a human pharmacy.
- - Discussed potential need for gabapentin prior to future vet visits.
- - Discussed the risk of serotonin syndrome and the need to monitor.
- - Advised that if the medication is effective long-term, regular blood tests (every 6 months) would be recommended to monitor liver function.
- - The medication should not be stopped abruptly.
- Owner education:
- - Advised on behavioural modification techniques in conjunction with medication.
- - Provide a designated safe space (e.g., crate or bed) that is exclusively his.
- - Learn to read his body language (e.g., signs of discomfort).
- - Use positive reinforcement training with high-value treats for obedience tasks (sit, stay, drop).
- - Recommended resources from Dr. Sophia Yin for dog behaviour and training.
- Follow-up care: Recheck consultation in 8 weeks to assess response to medication and behaviour changes. Owner to contact the clinic if any adverse effects are noted.

PLAN:
Continue monitoring ears.
Commence fluoxetine trial for anxiety.
Recheck in 8 weeks to review progress.