C09986244 / invoice 10000

Appointment Notes: earsWas scratching and head shaking for 10 days. Then went away, has restarted again even worseEars are smelly and very pink DUDE normalUTD vaccinationNo other medicationsNo v/d/s/cNo other concerns at this time Subjective:BAR - very nervous  Objective: HR/PR/CV: 120bpm, no murmurs, no arrhythmiasMM/CRT/Hydration: pink, hydrated, CRT <2RESP/RR: no abnormal lung sounds detectedTemp: n/tGIT/UG: abdominal palpation comfortable and unremarkableSkin/Ears: marked stenosis of ear canal bilaterally, marked erythema of internal pinna and tragus bilaterally, yellow malodourous discharge present in both ear canals. Unable to visualise TMM/S: ambulating normallyEyes: bright and clearLymph Nodes: NSFBCS: 5.5/9Laboratory:L: Malassezia pachydermatitis 13/hpf R: malassezia pachydermatitis 15/hpf + marked cocci infection Assessment: Bilateral OE (mixed infection) +/- TM rupture Treatment: Triz EDTA + Enrofloxacin + Dexapent 1ml both ears BIDPrednisolone 10mg PO SID for 3 days then EOD for 3 consecutive dosesPlan: F/U call 3 daysRevisit q 7 days     Vital Signs    Weight: 10.6;