C10012077 / invoice 10000

GapOnly Summary
In-House team to paste into OpenVPMS
Presenting Complaint
Recurrent otitis externa; ear inflammation.

Prior History
Yes; repeated history of ear infections with previous episodes noted in July 2024 and July 2025, requiring two treatments to achieve control.

Assessment
Ear inflammation, no active infection.

Treatment
- Cytopoint injection administered in clinic for ongoing allergic ear inflammation.
- Topical anti-inflammatory ear drops (non-systemic, to be instilled weekly in both ears for four weeks, then fortnightly for two months).
- Advice provided to gently clean ears with soft wipes only if needed; avoid over-cleaning.
- Scheduled follow-up appointment for repeat Cytopoint injection on 16 March.
Note: If further diagnostic clarification becomes necessary, reassessment is recommended.

Completed by Dr Oosthuizen
Consultation Date: 26/02/2026 18:06
HISTORY
- Presenting complaint: Atopic allergies with secondary yeast otitis, revisit for ongoing ear issues.
- Diet: Multivitamins and antioxidants mentioned. Owner uses natural products including silver on feet, previously in ears.
- Current medications & medical conditions: Allergies, secondary yeast otitis. Previous use of drugs for ears and systemic health. Use of ear and skin treatments including compounded yeast killer and natural silver product.
- Client concerns:
  - Ongoing ear issues, recurring wax and secondary infections.
  - Fluctuation in ear wax, concern about possible mites.
  - Management of atopic disease, frustration with recurrent symptoms.
  - Questions about ear cleaning technique and effectiveness.
  - Concern about redness and previous inflammation in paws, but improvement noted.

PHYSICAL EXAM
- Mentation: BAR
- Eyes: NAD
- Ears: Evidence of wax, brown debris, previous swelling, currently improved. No current flapping or irritation reported. Query white dots—confirmed as skin cells, not mites.
- Nose: NAD
- Oral: Pink mucous membranes, CRT <2 seconds
- Dental Grade: Brushing reported routinely. No detailed grading or findings documented.
- Lymph nodes: NAD
- Cardiac: NAD
- Respiratory: NAD
- Abdominal: NAD
- Genitourinary: NAD
- Musculoskeletal: Redness previously reported in paws, now improved. No lameness or arthritis.
- Neurological: NAD
- Skin & Coat: 5/5. Previous inflammation and redness on feet, now improved in colour. No chewing or licking reported currently.
- Anal Sacs: NOT DONE
- Temperature: NOT TAKEN
- Notes:
  - Ear canal examined for yeast and wax.
  - Owner reports gentle handling during treatments.
  - Feet treated with recommended natural products.

DIAGNOSTICS
- Clinical Examination
- Microscopy: Ear canal examined for yeast, skin cells, and mites. No mites identified, skin cells only.

ASSESSMENT
- Atopic allergies with recurrent yeast otitis.
- Fluctuating ear wax production.
- Previous severe paw inflammation, now improved.
- Owner frustration with ongoing management requirements.

TREATMENT
- Compounded antifungal ear medication ordered; to be instilled weekly until ear canal normalised.
- Owner instructed on ear cleaning techniques and gentle product application.
- Silver-based topical continued for paws as recommended.
- Transition plan to preventative product in ears after completion of antifungal treatment.
- Avoid cleaning or manipulating ears for two weeks as per advice.
- Ongoing monitoring of paw health.

COMMS
- No treatments declined; owner awaiting compounded medication order.

ADDITIONAL INSIGHTS
None

RECOVERY CALL
- Will enquire about improvement in ear wax, absence of irritation, and ongoing paw health.
- Will ask about response to new compounded medication and preventative regimen.