C09989346 / invoice 10000

Appointment Notes: ROOM 3   EARSNurse:Any concerns the owner has / presenting problem and duration: History:Previously presented for similar issue: yes/no Diet:Parasite control: Vacc history: Current medications:Vomiting / diarrhoea:Defecation: Urination: Eating/drinking: Exam:Mentation BAREyes - clear, cornea all appears WNL, no tear stainingEars - clearNose - clear, no dischargeOral - DS mm pink and moist CRT<2sThyroid palpation - all palpates normalLymph nodes - all WNLCardiac: HRRespiratory: Abdo - soft and pliableGenitourinary clearMSK - no pain on manipulation of joints, patellas non luxatingNeuro - clearIntegument - no masses palpableTempBCS 3/5Assessment: Plan:Revisit require: Y/N and whenHistory: Diet:Parasite control: Vacc history: Current medications:Vomiting / diarrhoea:Defecation: Urination: Eating/drinking: Any concerns the owner has: Exam:Mentation BAREyes - clear, cornea all appears WNL, no tear stainingEars - The right ear has erythema. The tympanic membrane is inflamed on otoscopic examination. The ear canal is mildly red with some ceruminous wax present. Cytology from the right ear shows cocci 2+ and Malassezia 1+ on higher power. The left ear is unremarkable.Nose - clear, no dischargeOral - DS 2 mm pink and moist CRT<2s; mild calculus in molarsThyroid palpation - all palpates normalLymph nodes - all WNLCardiac: HR 116 normal rate and rhythmRespiratory: 20 normal bv Abdo - soft and pliableGenitourinary clearMSK - no pain on manipulation of joints, patellas non luxatingNeuro - clearIntegument - no massess palpable, Temp- not takenBCS 3.5/5Assessment: 1. Otitis Externa Right earddx: bacterial (cocci vs rods), fungal (malassezia)right ear on physical examination has erythema to outer pinna. Otoscopic examination, TM intact with inflammation and mild ceruemous wax present. Swabs taken for cytology. Left unremarkable. Right cocci ++ with occasional malassezia present. 2. Discussed weight lossPlan:1. Dermotic 0.7 mls BID in right ear for 10 days, revisit on 11th    Vital Signs    Weight: 25;