C10018716 / invoice 10000

History:
- Right ear infection noted by owner - ear appears red
- Humid weather contributing to ear issues
- Ears cleaned at groomers
- Funny gait - under investigation with Sash, CT scheduled for Thursday
- Diet: half wet food (lyka), half dry food, morning and night
- Portions recently reduced per guidance
- Energy levels good, happy otherwise
- Whiny in mornings last couple of days - possibly ear-related

Physical Exam Findings:
- BCS: Extra padding present, ribs not easily palpable
- Behaviour: Good for examination
Ears: Right ear - very red, yeast present on cytology. Left ear - normal.
Integument: Hair growth noted in ear canals

Diagnostic Results:
- Ear swab cytology: Yeast identified in right ear

Assessment:
- Problem list:
1. Right otitis externa - yeast

Plan:
- Ear cleaning performed
- Ear drops prescribed: anti-yeast and anti-inflammatory, twice daily for 10-14 days
- Continue ear cleaning at groomers or with cotton wool balls at home
- Keep ear clean and dry during treatment
- Inform groomers of ear infection - avoid direct water, wipe down ears only
- Consider trimming hair around ears rather than plucking to avoid inflammation
- CT with Sash Thursday for gait assessment

Communications:
- Ear drop administration technique demonstrated - nozzle into ear canal directed toward nose, squeeze bottle twice, massage in
- Redness should settle over next few days
- May shake head or scratch after treatment due to liquid sensation
- Keep ear clean and dry while healing
- Results from Sash will be forwarded to clinic
SW

To whom it may concern, 

An AI scribe transcription error was identified within the consultation note dated 12/08/2025. The record was corrected to accurately reflect the history taken. 

For clarity:

    At the 12/08/2025 consultation, no gait abnormality or orthopedic disease was observed or diagnosed. The main reason for this visit was suspected kennel cough. 
    The owner’s comment regarding hesitation on one set of stairs down to his bedroom was considered behavioural, as Alfie remained comfortable using other stairs and showed no consistent mobility issues and no lameness. 
    Musculoskeletal examination was limited by nervousness, however range of motion was normal and no pain was elicited.
    There was no known hip dysplasia identified on parental screening scans or genetic testing ** This was the section that AI recorded incorrectly. 

This clarification is provided to ensure the medical record accurately reflects the clinical findings at the time of examination. 

Kind regards,

Dr Bridget Bliss 

Hello RB Vet team

We discussed this the other day and I understood Alfie’s records would be corrected as there was no prior diagnosis of a gait issues or hip displasia. 

It was only upon my most recent visit on 20 January where we agreed with Bridget that his gait looked a bit odd, and I took him to SASH on 5 February. 

During the visit on 20 January we established that an incorrect comment was transcribed on his previous records (I believe from AI) that referenced hip/gait issues. It was news to me and we agreed his records would be amended accordingly.

I would be frustrated if an error on his history will prevent us getting insurance coverage. 

Kind regards 

Andrew.