C10013338 / invoice 10000

Sore Ears
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HISTORY
Presenting for: Jack presented for ear examination due to head shaking and owner concern about possible ear infection in the right ear (previously had left ear infection in January treated with Neptra)
Historical Conditions: Left ear infection in January 2025 treated with Neptra
Current Meds: Gabapentin (ongoing), Librela monthly arthritis injection (due in 6 days)

EXAM
Mentation: BAR
Wt:
BCS: 6/9
T: NT
HR: 100
R: clear
MM: pink
Hydration: euhydrated 
Behavioural: Cooperative during examination, comfortable lying down in exam room (first time exhibiting this behaviour in clinic), accepted treats
Eyes: NAD
Ears: Bilateral ear canals contained excessive hair which was manually removed using hemostats. Post-hair removal: Right ear canal clear with no discharge, erythema, or abnormalities on otoscopic examination. Left ear canal mildly red and inflamed with minimal normal commensal organisms present on cytology. No significant pathological findings in either ear.
Diagnostics: Ear cytology performed on both ears - right ear completely clear, left ear showed minimal normal commensal organisms only

ASSESSMENT
Excessive aural hair growth - Hair removal performed, no underlying ear infection present. Head shaking likely due to hair irritation rather than infection.

PLAN
New Meds/Tx:
- Gabapentin prescription provided for ongoing use (1 tablet BID daily)
Additional Discussion:
- Discussed that regular hair removal from ear canals may be beneficial, especially before grooming appointments
- Advised owner to request groomer avoid getting ears wet but allow ear hair trimming
- Scheduled Beransa injection appointment for January 17th at 11:20am with nursing staff (due to grooming appointment ending at 10:30am)