C10001944 / invoice 10000

Reason: 2 Week Ear RevisitAppointment Notes: ------- Sms reply: YESVerified: NoHISTORYPresenting for: Luna, a 10-month-old female dog, presented for follow-up of bilateral ear infections following eardrum placement treatment.Historical Conditions: Previous bilateral otitis externa treated with eardrops, cleared after 6-7 daysCurrent Meds: Topical ear medication (0.4 mL BID) applied to right ear onlyOther: Patient escaped and ended up in bushes on Tuesday last week, possible exposure to grass seeds or bindisEXAMMentation: BAREyes: Left eye mildly puffyEars: Right ear canal showing reduced swelling, good response to treatment with minimal residue/discharge present. Left ear showing early inflammation with low numbers of Malassezia and inflammatory cells on cytologyIntegumentary: Mild hot pink inflammation on right leg with scratch mark. Mild generalised skin inflammation consistent with developing allergic dermatitisDiagnostics: Ear cytology performed on left ear - low numbers of Malassezia and inflammatory cells presentASSESSMENTBilateral otitis externa - Right ear responding well to treatment, left ear showing early inflammatory changes with yeast overgrowthDeveloping allergic dermatitis - Mild skin inflammation and scratching behaviour consistent with environmental allergies, likely to worsen with ageBehavioural reactivity - Both dogs become reactive to other dogs and people when walked together, but are well-behaved individuallyPLANNew Meds/Tx:- Topical ear medication 0.4 mL BID to left ear, massage after application- Topical anti-inflammatory cream BID to right leg scratch until redness resolvesAdditional Discussion:- Long-term allergy management discussed including monthly anti-allergy injections (Cytopoint) if infections become recurrent- Behavioural management advice provided: walk dogs separately initially, then parallel at 5 metres apart, gradually decrease distance as reactivity improves- Avoid triggers, use positive reinforcement for calm behaviour when other dogs pass- Regular ear cleaning recommended to prevent future infections    Vital Signs