C10032070 / invoice 10000

Reason: Recurrent bilateral otitis externaSubjective: EDDU normally, No V+ or d+O reports recurrent ear infections, shaking head constantly. Hx of ear infection noted at last vaccine visit. Previously on Apoquel approximately 1 year ago for 1 month with some improvement.Objective: BARHR/PR/Cardio: pulse normal and synchronous, CV normal, no audible murmurTemp: neMM/CRT/Hydration: pink, moist CRT 1 sec, hydration normalRESP/RR: NAD normal rate and effortGIT/UG: NAD comfortableSkin/Ears: Bilateral otitis externa - R ear red and moist, L ear infected appearing. Cytology - L ear bacterial infection and Malassezia, R ear Malassezia. Both ears inflamed with numerous WBCs on cytology. No head tilt, nystagmus or circling noted. TM not visualized due to discharge.M/S: NADEyes: NADDental: cleanLymph Nodes: wnlBCS: 5/9Nails clippedAssessment: Bilateral otitis externa (L ear bacterial and Malassezia, R ear Malassezia). Likely underlying allergic skin disease contributing to recurrent infections.Treatment: Ears cleaned in hospital. Dispensed Otomax 0.2ml bilateral SID-BID, Prednisolone tapering dose (1.5 tablets SID x 4 days, then 1 tablet SID x 4 days, then 0.5 tablet SID x 4 days). Multiple syringes provided for administration.Plan: Recheck in 2 weeks to confirm infection resolution. If clear, consider maintenance therapy with topical steroid treatment in ears plus regular ear cleaning to prevent recurrence. If develops head tilt, nystagmus or other neurological signs, stop drops and return immediately.____________________________INSURANCE HXInitial Assessment > Bilateral otitis externaSuspected cause > Otitis externaDate of first clinical signs > Recurrent problemAny other conditions / treatments > nails timmed    Vital Signs    Weight: 9.5;