C10011530 / invoice 10000

Appointment Reason: 1.4 CONSULT 4, Appointment Notes: recheck of ears. GT  ------- Sms reply: Y.Vet: Dr. Karen Burnett, BVSc,  REASON FOR VISIT  Elijah presented for a recheck of his chronic otitis externa and for assessment of red staining on his paws.    Presenting Concerns:-   Recheck of chronic otitis externa.-   Red staining on paws.  Other concerns:-   Annual vaccination is due.  Historical Conditions:-   Chronic otitis externa.  Diet:-   Fed Royal Canin Hypoallergenic diet.-   The O' is considering switching to filtered water.  Skin & Coat:-   The O' reports persistent red staining on the paws despite wiping with Malaseb wipes and using HCA spray q second day.-   The O' does not frequently observe him licking his paws.  Additional Information:-   The O' reports seeing some discharge from the ear when applying the spray.  Vaccination Status:-   Due for annual vaccination.  Preventatives:-   Nexgard, administered 1 week ago.  Current Medications:-   HCA spray applied to ears and paws q second day.-   Malaseb wipes used on paws q second day.PHYSICAL EXAMT: Not taken, HR: -, RR: -, MM: pink/moist. CRT < 2sec., BCS: /9  -   EYES: Clear, no ocular discharge or conjunctivitis.-   EARS: A small amount of discharge was noted in the AS canal. The AD canal was clean.-   NOSE: NAD-   THROAT: NAD-   ORAL / DENTAL: Mild plaque accumulation noted. Dental score: /4-   HEART SOUNDS: No murmurs or arrhythmias-   RESPIRATORY: Normal bronchovesicular sounds bilaterally.-   ABDOMINAL: No organomegaly or mass effects. No pain on palpation.-   EXTERNAL LN: NAD-   UROGENITAL: NAD-   RECTAL: Not performed.-   SKIN AND COAT: Saliva staining is present on the fur of the paws. No lumps noted.-   MUSCULOSKELETAL AND GAIT: Ambulation normal, no lameness observed.-   NEUROLOGIC: Normal mentation, no ataxia.  DIAGNOSTICS-   Ear cytology (AS): 1-2 yeast organisms identified in the entire sample.-   Ear cytology (AD): No Malassezia detected.-   Paw cytology (tape impression): Pollen, keratinized epithelial cells, and occasional Malassezia identified.ASSESSMENT-   Chronic otitis externa (AS) - Mild inflammation with a low number of yeast organisms present. The AD is well-managed.-   Pododermatitis - Suspected allergic origin, currently managed with topical therapy. Cytology revealed occasional Malassezia.-   Saliva staining - Cosmetic issue on the paws secondary to licking.-   Mild dental plaque-   Fit for vaccination  ADDITIONAL DISCUSSION  -   The red staining on the fur is due to compounds in the saliva and is a cosmetic issue. It will remain until the stained fur is shed or trimmed. The O' is considering trying filtered water, but it was explained that there is no scientific evidence this will resolve the issue.PLANTREATMENT  -   C5 vaccination administered (Protech C4, Batch: 5257038B, Expiry: 27/01/2027; BroncoShield Oral, Batch: 5245060A, Expiry: 14/04/2027).-   Dispensed HCA spray with added antifungal medication.  PLAN  -   Apply the new HCA spray with antifungal to the AS q second day (e.g., Monday, Wednesday, Friday).-   Apply the plain HCA spray from the current bottle to the AD and paws q 4 days (e.g., Monday and Friday) until the bottle is finished.-   Once the current bottle is empty, use the new antifungal spray for all affected areas according to the revised schedule.-   Continue wiping paws with Malaseb wipes. Instructions for preparing new wipes (10 mL Malaseb in 200 mL water added to a packet of baby wipes) will be emailed to the O'.-   Continue parasite prevention with Nexgard Spectra.-   Continue Royal Canin Dermacomfort diet.-   Recheck in 1 year for annual vaccination.  This document was generated with the assistance of CoVet AI to support accurate and efficient documentation.    Vital Signs    Weight: 23.5;