C10004539 / invoice 10000

05/03/2026 Ears

History: recurrent OE, previously treated with mometamax and systemic AB/pred. L ear most often the problem. Shaking head and tilting sometimes. Flared up in the last 2 days. Stress seems to make pruritus worse.
Chicken allergy, maybe a bit seasonal as well? 
Diet: novel protein. 

CLINICAL EXAM: very, very difficult to examine. Not aggressive but big strong dog who will not tolerate ear examination. Impossible to scope conscious. Took a lot of work to get cytology swab.
Left ear: pinna has mild erythema and some crusty discharge around ear canal. Smells bacterial. 
Right ear: pinna appears NWL, no smell noted.

LABORATORY:
Cytology L ear: cocci +++ intra and extracellularly, yeast+, no rods

TREATMENT:
Chatted about options for recurrent otitis. Discussed mometmax despite TM unknown vs systemic pred+AB's. Also discussed referral to dermatologist as problems have been ongoing and difficult to manage, especially given his hate for topical ear meds. O is keen for referral. Also discussed gaba/traz for future ear visits, o keen to try. Dispensed 4x doses so o can try at home and evaluate effect. O very grateful for help today. 
- Mometamax 0.8ml in L ear

C/C 7d.
Recheck one month if clinically well to ensure improvement, with gaba/traz on board. Earlier if no improvement. 


06/03/2026 DS: referral sent to Veterinary dermatology specialists