C10004029 / invoice 10000

09/03/2026 **History:**
Presenting for ear concerns. Head shaking noticed approximately 2 days ago. Scratching at ears. No ear medication at home. No scratching elsewhere or licking feet. Normal scratching behaviour otherwise. Eating and drinking well.

**Examination:**
Left ear: erythematous, evidence of scratching.
Right ear: more severely affected, very red, scratching noted.
Otoscopic examination: unable to visualise eardrums bilaterally due to discharge/wax covering.
BAR
MM:MPG
Dental : 2
abdomen : nad
BCS 4

**Cytology:**
Bilateral ear infection confirmed. Left ear: bacteria and fungi present, low numbers. Right ear: more severe infection.

**Assessment:**
Bilateral otitis externa.

**Plan:**
Ear drops: apply for 14 days, safe for use if tympanic membrane perforation present.
Prednisolone: tapering course over approximately 2 weeks. Administer with food to prevent vomiting and diarrhoea.
Topical cortisone: apply to affected skin areas around ears.
Gloves provided for application.
Counselled on potential side effects: increased drinking, urination, appetite. Advised not to increase feeding. Side effects should resolve once medication ceased.
Discussed possible aetiology: water exposure at groomer or environmental allergies.
Advised to delay grooming until ear infection resolved.
Review in 7 days.