C10021692 / invoice 10000

Reason: Room 2Appointment Notes: wax in ears. ds 11/3Entered by DVM: Checked by AED N8707Presenting complaint: wax in ears Summary of current diagnoses: behavioural issuesCurrent medications: fluoxetine 20 mg BID, has trazodone script for stress events but has not needed Specific History: The owner has recently noticed brown ‘gunk’/wax around both ears. No scratching or head shaking noticed. Chloe does regularly swim in the dam.No history of ear infections. Does not typically itch/scratch, except some paw licking when crated. Non-Specific history:Diet: blackhawk kibble Previously had another labrador at home who passed about 2 months ago, Chloe at the time was out of sorts for 1-2 wks but now doing well. Sentinel Spectrum for worming/flea control and heartworm (note for next visit/recheck this does NOT prevent ticks have not communicated to owner yet)Behaviour has been well controlled with fluoxetine, still cautious around new peopleOverdue for KC & C2i vaccinations and not performed at another clinic. Examination: Mentation: BAR, anxious & excitedRR: pant HR: not attained due to wiggling/audible panting, auscultation NAD, pulse quality good MM: pink & moist Dental: NAD LNs: normalNeurological: mentation normal so full neurological exam not performedIntegument: coat quality good, no evidence of licking around paws Temperature: not taken given anxiety and priority to examine earsAbdomen: tenseMusculoskeletal: ambulatory and no lameness presentEar exam:Grossly: mild brown wax present on pina, not obvious heat or erythemaOtoscope exam: left and right tympanic membranes visualised and intact, mild erythema of ear canal, minimal exudate/wax visualised. Chloe is more painful/reluctant on examination of the right ear compared to the left. Cytology performed on each ear - occasional yeast present. PROBLEM LIST:Brown waxPainful right ear Cytological evidence of malassezia 1-2 PHFAssessment:DDx:Mild otitis externa due to malassezia infectionAetiology/predisposing factors:- Most likely humid weather - Swimming in the dam - +/- atopic dermatitis/allergies Treatment:Dermotic - apply 0.2-0.4 mls/one generous squirt twice daily for 10-14 days. Plan:Ideally would have been nice to clean the ears today but given temperament and the mild infection this was not attemptedCommunicated to the owner the instructions for dermotic and how to apply. Advised that ideally we have a recheck in 2 weeks to repeat the cytology - owner may not be able to do this but will have Chloe brought in if it does not improve or application of drops not possible.The owner is pregnant and warned that a steroid is in dermotic and to consider gloves when applying and not to consume the medication. Advised owner to limit or stop all swimming in the dam at the moment and to consider weekly ear cleaning with all paws cleaning solution.Possibility of allergies being the cause mentioned to the owner, but explained that swimming/humid weather is more likely at this stage. The owner did not need a repeat of fluoxetine script at this stage. The owner declined KC or C2i vaccination today.    Vital Signs