C10011122 / invoice 10000

Reason: Ear Infection CCEHAppointment Notes: EDDU normally - cleaned ear on weekend - smells, scratching, shaking head. CCEHHISTORY:Diego presented for assessment of his ears. The owner reports a history of recurrent ear infections, with the last episode in late 2024. The ears are currently irritated and have an odour described as smelling "like beer", suggestive of a yeast infection. There is also a history of infected jowls/lip folds which are managed with weekly cleaning with Malaseb. The owner has been using Epiotic at home.Current meds: noneProphylaxis: Vaccinations are up to date. Simparica Trio is slightly overdue, last given approximately 2-3 months ago.Pre-existing conditions: Recurrent otitis externa. Recurrent lip fold dermatitis.Access to toxins eg. Rodenticide: NoneEXAMINATION:Body Condition Score: 5/9Pain Scale (0-4): 0/4Hydration status (%): hydration clinically adequateCardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: neurologically no significant findingsMusculoskeletal: ambulating normally, no palpable neck, spine, limb or joint painGastrointestinal:- Oral: normal, no mouth pain, dental score (1-4):2- Abdominal: no detectable pain on abdominal palpation, normal gut sounds- Rectal: Not performed.Urinary: NSFReproductive: NSFIntegument/Ears: Both ear canals are inflamed, and there is a large amount of waxy discharge present. The left ear is more severely affected than the right. Otoscopic examination was not performed due to the degree of swelling and discharge, as it would cause discomfort.Lymph Nodes: NSFEyes: NSFASSESSMENT:1. Bilateral otitis externa, secondary to Malassezia overgrowth. Worse in the left ear.LABORATORY:Ear swabs were taken from both ears for in-clinic cytology. Microscopy confirmed the presence of yeast in both ears, with a higher burden in the sample from the left ear.DIAGNOSTIC IMAGING:NoneTREATMENT:- Dispensed PMP ear drops.- Instructed owner to treat both ears.- Administer approximately 1mL into each ear canal once daily for 5-7 days.- Advised owner not to use the long nozzle provided, but to use the shorter applicator for administration.- Owner was advised to massage the base of the ear after application.PLAN:Re-examination is recommended if the ears have not improved after the 5-7 day course of treatment, or if the signs recur after stopping the medication.CLIENT COMMUNICATION:Discussed the diagnosis of a yeast ear infection. Explained the treatment plan and demonstrated the correct technique for administering the ear drops. Advised on the importance of completing the full course of treatment and the signs that would warrant a revisit. The owner is experienced in managing Diego's ear and skin issues.--- 09/03/2026 10:04:32 AM ANS:Examinations - Resolved - Follow up sms sent.    Vital Signs    Weight: 15.3;