C09988725 / invoice 10000

Reason: Possible Ear Infection EMAppointment Notes: started shaking head today, ears are a bit smellyHistory: O notes this morning, was shaking head a lot and scratching at R ear. O changes in EDUD, still happy in himself. Examine:Body condition score: 7/9Eyes: NADEars: difficult to perform otoscopic exam as patient non-compliant - L ear nil waxy discharge, no erythema. R ear moderate waxy discharge and erythema, unable to visualise tympanic membrane. On cytology, L NAD, R ++malassezia and +cocciTeeth/mouth: mild tartar on upper and lower arcade, otherwise NADChest: difficult to auscultate as panting, no audible murmurAbdomen: NAD on palpationUrogenital: NADDigestive: NADLymph nodes: submandibular, prescap and popliteal WNLSkin: NADLocomotion: ambulating well in consultNervous System: BAR (anxious but good for exam), normal mentationAssessment:Otitis externa R ear, obese, G1-2 dental disease, otherwise clinically wellDifferential Diagnosis:Malassezia and bacterial (cocci) otitis R ear v poss FB Plan:Informed consent granted. Discussed findings with O, adv dermotic BID for 14d, then recheck with vet. Adv if no improvement in 7d time, recheck with vet sooner. O happy with plan.    Vital Signs    Weight: 18.8;       MMColour: pink;       HeartRate: 130;       BodyScore: 7/9;       DentalGrade: 1-2;       RespirationRate: panting;       CRT: <2s;