C10025342 / invoice 10000

Reason: Ear / InfectionAppointment Notes: Booked Online: 12/03/2026 08:02:32 AMBooking Type: Skin, Ears, Eyes or LumpsBooking Notes: Ear infectionOwner Name: Ashley DavisonOwner Email: ash@psychprofessionals.com.auOwner Mobile Number: 0408840433Pet Name: LolaPet Species: DogWeb BookingClient name: DavisonContact number: 0408840433Email address: ash@psychprofessionals.com.auPatient name: LolaHISTORY:Presented for head shaking, which started over the weekend. The owner reports Lola was shaking her head frequently on Friday and Saturday night. She is eating and drinking well, with no vomiting or diarrhoea. Mobility is normal. No head tilt or nystagmus was observed by the owner. There is a history of one previous ear infection.Current meds: noneVaccination: Not mentionedParasite Prevention: monthly milbemax for HW and monthly nexgardPre-existing conditions: History of a single previous ear infection.Access to toxins eg. Rodenticide: noneDiet: LycaEXAMINATION:Body Condition Score: 5/9Cardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: neurologically no significant findingsMusculoskeletal: ambulating normally, full examination not completedGastrointestinal:- Oral: normal, no mouth pain, dental score (1-4): 2- Abdominal: no detectable pain on abdominal palpation- Rectal: not performedUrinary: NSFReproductive: exam not performedIntegument/Ears: Significant ceruminous and malodorous discharge from the left ear. The right ear has some discharge present but is less affected.Lymph Nodes: NSFEyes: NSFDemeanour/Behaviour: not discussedPain Scale (0-4): 0/4Hydration status (%): hydration clinically adequatePROBLEM LIST:- Bilateral otitis externa (right worse than left)- Head shaking- Malodorous aural dischargeDIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:Bilateral yeast otitis externa (Malassezia otitis). Left ear more severely affected than the left.DIAGNOSTICS:Ear cytology performed on samples from both ears.- Right ear: Significant yeast infection.- Left ear: Scattering of yeast present.ASSESSMENT:Lola has a bilateral Malassezia otitis externa, which is more severe in the Left ear. The right ear is also affected and requires treatment to prevent progression. Clinical signs are consistent with the diagnosis.TREATMENT:Medication prescribed for application to both ears.- 0.5 mL to be administered into each ear canal once daily for 7 days.Owner was instructed on the correct administration technique, including massaging the base of the ear canal after application and before allowing Lola to shake her head.PLAN:- Administer ear medication daily for 7 days.- A recheck consultation is recommended at the end of the treatment course to ensure complete resolution of the infection.- Lola to be kept out of water (no swimming or bathing) during the treatment period. If ears get wet, they should be dried thoroughly.- Home into owner's care.CLIENT COMMUNICATION:Discussed the diagnosis of a bilateral yeast ear infection. Explained that the moist, hairy ear canal environment predisposes her to such infections. Provided detailed instructions on how to administer the ear medication. Advised on the importance of a follow-up visit in 7 days to confirm the infection has resolved. Signs of resolution to monitor for at home include cessation of head shaking, no smell, no discharge, and no redness. Advised to avoid swimming or bathing during treatment.    Vital Signs    Weight: 7.2;       HeartRate: 120;       DentalGrade: 2;       RespirationRate: pant;       CRT: <2secs;       MMColour: pink;       BodyScore: 6;