Veterinarian
History:
* Presenting complaint: "Coco" (Canine, Staffordshire Bull Terrier, entire male, 4 years old) presented for a 3-day history of scratching his left ear and shaking his head. Owner reports a reddish discharge noted this morning.
* Duration: 3 days.
* Background information: Coco is an indoor/outdoor dog, up-to-date on vaccinations, and has no known allergies. No recent changes in diet or environment. He has a history of occasional ear infections, typically responding well to topical treatments.
[List of current medications]
* Pre-emptor (Afoxolaner/Milbemycin oxime) – monthly, last given 25 October 2024.
* Nexgard Spectra (Afoxolaner/Milbemycin oxime/Praziquantel) - monthly, last given 20 October 2024.
Examination:
Body condition = 4/9 (ideal)
Weight = 25.4 kg
Dental exam = Mild tartar noted on canines and premolars.
Demeanour = Bright, alert, and responsive; slightly head-shy when left ear approached.
Oral mms-Pink, moist, CRT <2 seconds
Chest auscultation-Heart rate 110 bpm, strong, regular rhythm. No murmurs or arrhythmias detected. Lung sounds clear and vesicular.
Respiration-Eupnoeic, no increased effort. Respiratory rate 20 breaths/minute.
Abdominal palpation-Soft, non-painful, no organomegaly or masses detected.
Lymph nodes-Peripheral lymph nodes non-enlarged.
Mentation-Alert and appropriate.
Skin/coat-Coat is shiny and well-maintained. Mild erythema and excoriation noted around the left external ear canal.
Eyes-Clear, no discharge, pupils responsive to light.
Ears-Left ear canal erythematous with a moderate amount of reddish-brown, waxy discharge. Mild swelling of the pinna. Right ear appears normal.
[Temperature]
Rectal examination-Not performed
Laboratory:
* Left ear cytology: Abundant cocci bacteria and moderate numbers of Malassezia yeast. Occasional neutrophils noted.
Assessment:
* Otitis externa, left ear, consistent with bacterial and yeast overgrowth secondary to inflammation.
* No signs of systemic illness or underlying foreign body in the ear canal at this time.
Treatment:
* Cleaned left ear canal with a gentle otic cleanser.
* Administered antibiotic and antifungal ear drops into the left ear.
* Provided anti-inflammatory injection (given in consult).
Plan:
* Prescribed topical ear medication for twice daily application for 10 days.
* Recommend recheck in 10-14 days to assess response to treatment and repeat ear cytology.
* Discussed potential underlying causes of recurrent otitis and recommended considering allergy work-up if condition recurs.
* Advised owner to monitor for any changes in appetite, activity, or worsening of ear symptoms.