C10000871 / invoice 10000

07/03/2026 HISTORY
Presented for follow-up of ear issues and persistent head tilting, particularly affecting the right ear side.
Historical Conditions: Previous ear infection treated with ear drops approximately 2 weeks prior to last visit. Head tilt noted as ongoing issue from previous consultation.
Diet: Appetite returned to normal since starting current medications. Previously ate significantly more than usual during illness period approximately 2 weeks ago.
Current Meds: Prednisolone, Amoxicillin-clavulanate

EXAM
HR: 180, no murmur
R: clear lung fields
MM: pink, CRT <2s
Behavioural: Cooperative for examination, some resistance to ear handling
Ears: Right ear shows some discharge/muck but not severe. Left ear appears clean. Head tilt less frequent now, mainly occurs when right ear is touched or scratched. Otoscopic examination revealed tympanic membrane appears intact and white, unable to visualize behind TM.
Oral: Bad tooth noted in upper right arcade, contributing to discomfort on right side of face
Neurologic: Persistent but improved head tilt, primarily when right ear area is manipulated
Diagnostics: Ear cytology from both ears performed. Right ear sample showed bacteria and Malassezia present. Left ear sample appeared clean with no significant findings.

ASSESSMENT
Otitis externa - Right ear showing persistent bacterial and yeast infection based on cytology. Possible concurrent middle ear involvement given history of head tilt and intact tympanic membrane preventing visualization of middle ear structures.
Dental disease - Bad tooth noted contributing to facial discomfort on right side.

PLAN
New Meds/Tx:
- Dermotic ear drops for right ear, twice daily
- Continue amoxicillin-clavulanate for additional week
Changes to Existing Meds/Tx:
- Discontinue prednisolone (finish remaining 1-2 tablets)
Additional Discussion:
- Discussed treatment approach: continuing antibiotics alone vs. combination therapy.
- If condition worsens after stopping steroids, inflammation likely primary issue, infection likely secondary
- Topical ear treatment more effective for outer ear infections, systemic antibiotics better for middle ear involvement
- For dental care: recommend pet toothpaste and brushes, dental wipes as easiest option for cats - will not fix bad tooth but slow down worsening dental disease
- Tablets can be crushed and mixed with wet food if needed for administration
Client Comms:
- Return in one week for recheck examination and ear assessment
- Monitor for worsening head tilt - return sooner if this occurs