C09975861 / invoice 10000

HX:
Client reports chronic hx of ear issues 
Has been shaking head more freq for the past week or so 
Today when taken outside seemed very agitate and uncfmrtable, found some frank blood on under side of ear pinnae
Does not go swimming
Otherwise well in herself, no signif pruritus elsewhere
eddu ok, no v/d

CE:
BAR 
Eyes, nares nad
Oral G2-3 periodonta disease
MM pk, moist, CRT <2s
HR wnl, no murmur, normal rhthm
Pant, effort ok, lung fields ausc clear

Ears
R: evidence of self trauma with superficial scratches near entrance to ear canal, bruising on innder pinnae suspected secondary to ear flapping, no swollen haematoma. Very erythematous, sensitive and pruritic. Otoscopy: no foreignbody obsv, unable to view TM due sensitivity and copious discharge. Discharge is a mix of yellow pus, and dark brown-red tinged 
L ear: moderately erythematous, sensitive and pruritic. moderate voumes brown discharge in canal, Otoscopy: too sensitive to tolerate in this ear but no fb observed

Cytology
R: cocci 4+ (COPIOUS!), rods 1+
L: malasezia 3+, cocci 1+

Plan:
Client elect long-acting medications for bilateral otitis externa due to concern ability to administer daily topical tx
Also ear flush concious and pred course to help reduce severe inflammation and itch
To revisit in 1 month to recheck ears - if infection resolved to consider ordering in elocon t use once weekly as maintenance anti-inflammatory with aim of reducing incidence otitis

TX:
R ear flushed with otoflush until clear
Mometamox 0.8ml administered into each ear 
Pred20mg oral tapering course:  1/2tab PO SID x 6d, then 1/2tab PO EOD x 4 doses