C10016742 / invoice 10000

10/03/2026 [BH]
Weight (Kg):33.30
History:Presenting complaint
Recheck examination for severe otitis externa.

History

- Patient was evaluated one week prior for a severe ear infection.
- Previously treated with Meloxicam and doxycycline via SASH.
- Owner reports patient is much improved overall.
- Medicated bathing has resolved skin issues.
- Appetite and thirst are normal.
- A yeasty odor is still present.
- Owner identified a new small skin mass on the abdomen this week.

PEx:
BCS 5/9
BAR
MM PM, CRT <2
HR: no arrhythmia/murmur detected
Resp: normal bronchovesicular sounds, eupneic
Oral: good teeth
Ear: Yeasty odor appreciated. Right ear canal is markedly erythematous and inflamed. Left ear canal is less severely affected, improved from last week however still painful
Integ: Small, black, raised cutaneous mass on the right ventrolateral abdomen. Non-painful on palpation.
LN: within normal limits
Abdo: soft comfortable, no obvious organomegaly, no abnormalities detected

Assessment
Bilateral otitis externa, severe, with significant inflammation, worse in the right ear.
Cutaneous mass, right ventrolateral abdomen; differentials include skin tag, melanoma, mast cell tumor.

Treatment
Prednisolone 20mg: 1 tablet PO SID for 4 days, then 3/4 tablet PO SID for 2 days, then 3/4 tablet PO EOD for 3 doses.

Client communication

- Discussed rationale for prescribing corticosteroids to decrease severe aural inflammation.
- Explained that reducing inflammation improves efficacy of topical medications and provides relief.
- Potential side effects of steroids (PU/PD, polyphagia) were reviewed, though noted as unlikely at this dose.
- Advised owner to monitor the new abdominal skin mass for any increase in size.
- Recommended future removal of the mass if it grows
- Explained removal could likely be performed under sedation with local anesthesia.
- Suggested discussing the timing of the procedure with the specialist managing his orthopedic condition.
- Confirmed medication can be given with or without food.

Plan
Osurina OTB 12/3/26 (already paid for)
RC ears 19/3/26

BH