C09977209 / invoice 10000

Appointment Reason: Check Ears, Appointment Notes: Shaking head, seems to have irritation in earsAlso has been scooting bottom recentlyin with Christopher (son)History: Over the last week has been shaking his head, bad smell to ears Has been scooting his bum recently too, has maybe has AG issues once in the past Otherwise doing well in himself EDDU as normal A bit of trouble sleeping Objective: BAR, well behavedIntegument: coat nsf, no perianal hairloss or erythema Eyes/nose - nadEars: - L ear: moderate-marked erythema external ear canal, moderately swollen ear canal, copious amounts of light yellow discharge on otoscope exam- R ear: mild erythema external ear canal, moderate inflammation with dark brown ceruminous discharge on otoscope exam Rectal: L AG mildly full, R AG nothing to express Laboratory: Ear swab: - L ear: yeast +2, cocci +4, rods +1- R ear: yeast +4 Assessment: Bilateral otitis externaTreatment: Gently cleaned L ear with swabs Aurizon ear dropsPlan: RV at end of treatment course to recheck ears or sooner if scooting does not improve 02/03/2026 3:13:18 PM MB:request for PI put through to LDG    Vital Signs    Weight: 30.28;