C10013510 / invoice 10000

11/03/2026 NURSE: MS

HISTORY:
- Hx recurrent ear infections.  
- Ears and periocular area appear red/inflamed currently. 
- Inflamed ears predispose to ear infections. 
- Not keeping her up at night or scratching excessively. 
- Also gets rash underneath belly.

CLINICIAL EXAM:
- Mentation: BAR
- MM: Pink, moist
- CRT: <2s
- Oral and Dental Score: Grade 1-2
- Eyes: Periocular redness noted R eye
- Ears: Bilateral ear redness/inflammation. Ears swabbed
- BCS: 4/5
- Lumps: NAD
- Abdominal: Comfortable
- Lymph nodes: WNL
- HR: 132 bpm
- RR: Clear sounds
- Temp: Not assessed
- Urogenital: WNL
- MSK: Amvbulating well 
- Skin: Redness under lips. Rash underneath. Inflamed ears

CYTOLOGY (Ears):
L: Cocci 4+
R: Cocci 4+, occasional rods

ASSESSMENT:
- Bilateral otitis externa - inflammatory. Periocular dermatitis. Lip fold dermatitis. R/O early infection.

VACCINATION:
Vaccine: Protech Pi2
Batch: 5264018
Expiry: 25.02.2027
Vaccine: Protech Bronchi-shield oral
Batch: 5245047A
Expiry: 10.02.2027

DISCUSSION:
- Discussed Apoquel for skin inflammation - can use PRN or daily if needed frequently. Doesn't need to be weaned.
- Discussed once weekly anti-inflammatory ointment for ears once infection cleared - can reduce ear infection frequency significantly.
- Long-acting gel covers both round & rod bacteria.
- Gel stays liquid at fridge temp - store in fridge, gentle mix before use.

TREATMENT:
- Ear swab collected for cytology
- BOVA dex enro keto 1ml in each ear + 2ml to take home and apply in roughly one week
- Apoquel 16mg SID PO
- Trazodone 150mg PRN

PLAN:
- Home with Apoquel
- O to apply ear medications before flying out 16th March
- RV booked for 26/3 to resmear ears
- Once infection clear - start weekly anti-inflammatory ointment (Elocon - previously used September 2025).