C10015803 / invoice 10000

PRESENTING/OWNERS CHIEF COMPLAINT/REASON FOR VISIT
Otto presented for assessment of a potential right ear infection. The owner reports he has been shaking his head and there is discharge inside the ear. This was first noticed last Friday after a bath.

Consult Nurse
Maddie

History
EDDU: Normal  
Vomiting/Diarrhea: No V+ or D+  
Diet: Cooked chicken, rice, and vegetables with a small amount of Hill's t/d kibble in the morning.  
Vaccinations: Up to date. C6 vaccination administered on 03/12/2025.  
Preventatives:
-   Worming: Up to date with Milbemax.
-   Heartworm: Up to date with ProHeart SR12, administered on 03/12/2025.
-   Flea & Tick: Up to date with Bravecto, given every 3 months.
Current Age: 5.5 years  
Current Medications: None.  
Behaviour Concerns: Can be reactive and may bite when his ears are handled, especially when painful.  
History: The owner suspects water may have entered the ear during a bath last week. There is a history of previous ear infections. The owner has been using Otoflush at home, but the condition has not improved.

Physical Exam
General Appearance: BAR; Bright, alert, and responsive. Weight: 7.2 kg.  
Behaviour: Anxious during examination, required a muzzle for otoscopy.  
Vitals: HR: 120 bpm; RR: RR;pant T: not assessed; MMC: Pink; CRT: <2s  
Hydration: normal  
BCS: 6/9  
EENT: eyes clear, no evidence of conjunctivitis, no discharge or blephrospasm; The right external ear canal is severely swollen and inflamed, preventing visualisation of the tympanic membrane. A purulent discharge is present. The left ear canal has mild changes. no nasal discharge; Severe tartar accumulation and marked gingivitis noted.  
Cardiac: normal rate and rhythm, no murmurs on auscultation. A normal sinus arrhythmia was noted.  
Resp: normal rate, normal clear sounds auscultated in all lung fields  
Abdo: comfortable on abdominal palpation, no palpable abnormalities  
Urogenital:  nsf-desexed
Integument: no external parasites noted; no erythema or pruritis  
Neuro: proprioception NAD; NSF  
Musculoskeletal: ROM in all joints NAD; no abnormalities on palpation  
Lymph Nodes: Peripheral LN's WNL

Client Communication from Consult Nurse
Maddie assisted with restraint and placing a basket muzzle on Otto to allow for a safe examination of his painful ears.

Client Communication with Vet
A detailed discussion was had with the owner regarding Otto's history and the plan for the consultation. An estimate of $259.90 for the consultation and ear cytology was provided and accepted.  
  
The owner inquired about a single-dose, long-acting ear treatment. I explained that these medications are typically reserved for more resistant infections, and using them for a primary infection could contribute to future antimicrobial resistance. It was agreed to proceed with cytology first to guide treatment.  
  
Following the examination, I explained that the right ear canal is severely swollen and inflamed, to the point where the eardrum (tympanic membrane) could not be visualised. I communicated my concern that the eardrum may be ruptured due to the severity of the inflammation. I explained the risk of ototoxicity (potential for neurological side effects like head tilt, circling, or balance issues) if certain medications pass through a ruptured eardrum.  
  
Based on these findings, I recommended a treatment plan which the owner accepted:
1.  A custom-formulated ear medication that is safe to use in the event of a ruptured eardrum.
2.  A tapering course of oral steroids (prednisone) to rapidly reduce the severe inflammation and pain in the ear. The common side effects of increased thirst, hunger, and urination were discussed.
  
The results of the ear cytology were reviewed with the owner. The right ear showed a significant yeast infection (3-4+ yeast) with a large number of inflammatory cells (white blood cells). The left ear showed a mild bacterial infection (2+ cocci). It was recommended to treat both ears.  
  
I provided a dental estimate, as significant tartar and gingivitis were noted. The owner expressed frustration as a dental procedure was performed in late 2025.  
  
A recheck appointment in 7-10 days was strongly recommended to ensure the infection has fully resolved. The importance of follow-up cytology was explained to prevent recurrence from an incompletely treated infection.  
  
The final invoice total was $693.50. The owner provided RSPCA pet insurance details (policy RS11992244) to submit a GAP claim.

Laboratory/Imaging
Ear Cytology:
-   Right Ear: 3-4+ yeast and numerous white blood cells were present, indicating a significant inflammatory response.
-   Left Ear: 2+ cocci bacteria noted.

Assessment/Problem list
-   Severe Malassezia otitis externa (right ear) with marked inflammation and suspected tympanic membrane rupture.
-   Mild bacterial (cocci) otitis externa (left ear).
-   Severe periodontal disease.
-   Mildly overweight (BCS 6/9).

Treatment
Medications Dispensed:
-   Custom Ear Solution (Enrofloxacin/Dexamethasone/Saline): Administer 0.5 mL into each ear twice daily for 7 days. A double volume was supplied.
-   Prednisone tablets 0.8 mg/kg (x10 tablets): Give 1 tablet once daily for 5 days, then 1 tablet every other day for 3 doses, then 1 tablet for 2 days until finished.

Plan
-   Begin course of oral prednisone and custom ear drops as prescribed.
-   Monitor for any adverse effects, particularly signs of vestibular disease (head tilt, circling, loss of balance), though the prescribed ear drops are non-ototoxic.
-   Recheck appointment booked for Wednesday 17/03/2026 at 1:30 PM for a progress examination and repeat ear cytology. This is crucial to confirm the infection is resolved.
-   The owner was provided with a dental estimate to consider for the future.
-   Once the current infection is resolved, recommend routine use of Otoflush ear cleaner to help prevent recurrence, especially after bathing or swimming.
  
(GHC in 6mths)

Internal treatment plan Comms
Patient has severe inflammation in the right ear, preventing visualisation of the tympanic membrane. Treating with a custom non-ototoxic solution (Enrofloxacin/Dexamethasone in saline) and a tapering course of prednisone. The left ear has a mild cocci infection, so treating both ears. A double volume of the ear solution was dispensed to the client. A dental estimate was also sent home.

Follow up notes
A recheck appointment has been scheduled for Wednesday, 17/03/2026 at 1:30 PM.  
Follow up phone call for: 2-3 days
                                                   

Hx from North Bundy Vets

+ Paw Pads 
prebooked

Groomer: MGC

Grooming Details:
Paw pads: (Y)
Nails Trimmed: (Y)  

Animal's Behavior : (Very good boy!!!, does not like being dried on head and front legs)

Microchipped: (Y)

Recommended Next Groom in: (6) weeks time