C10016993 / invoice 10000

NOTES: Reason: ear infection 

HISTORY:
Presented for ear infection, last one end of last year that resolved with apex 
Has had slightly itchy paws too but not too bad 
Went to groomers two weeks ago, then head shaking started shortly after
O hasn't been able to pluck ear hairs as well due to new nails 
Hasn't noticed a general pattern or anything with itching/ear infections other than after grooming/wetting 
Otherwise well, no other concerns 

General:
Vacc and parasite prevention UTD 
EDDU. No change in diet. No V+ or D+. 
No coughing or sneezing.
Activity levels normal. 

EXAMINATION: 
Mentation: BAR - lovely boy, very sweet 
BCS: /9
Eyes/Nose: clean and clear of discharge, no erythema, no odour 
Ears: small amount of brown discharge, TM intact on otoscopic exam, no erythema or odour 
Dental: Grade 1 dental disease present, mild tartar present, no gingivitis present. 
Cardiac: HR 110, no murmur or arrythmia ausculated 
Resp: RR 28, normal rate, pattern and effort, clear bronchovesicular sounds bilaterally, no crackles or wheezes
Abdo: soft and comfortable on palpation 
MSK: ambulatory x4, normal gait, no lameness
Neuro: mentation appropriate, no obvious cranial nerve deficits or ataxia 
Integument: clean skin and coat

DIAGNOSTICS: Cytology
Diagnostic results:
right ear: moderate yeatsts ++ (>20 per hpf) 
left ear: mild yeatsts + (10 per hpf) 

ASSESSMENT:
1. bilateral otitis externa - ddx overwetting > vs allergies (food vs environmental vs atopy) vs infectious vs FB vs other

PLAN: 
Diagnostic/treatment plan:
1. Apex PMP 0.5mls BID both ears for 2 weeks 
2. Easotic cleaner a couple of times a week then once weekly after infection resolves 
3. Keep ears dry after grooming 
4. Provided antihistamine chart if paws continue to itch or flare up  

COMMS:
Discussion of plan including signs to look out for and medication usage/risks - O comfortable with apex and has used before 
Advised ear infections may be from over wetting or could be underlying allergies - if they continue to occur we may need to look at either medication trial for allergies or further work-up to find underlying cause - O understands 
Revisit: 14 days
O happy with this plan

WEIGHT: 7.50
BLDRQ: N
CLIN_EXAM: - PO aok
- ears nad now 
- O is aware of plucking aural hair
WRMRQ: N
FLRQ: N

NOTES: 26 Aug 2025 11:53:31 am RMW - doing well. Eating/drinking/toileting.