C09992963 / invoice 10000

Appointment Notes: Follow up with BO. CB   ------- Sms reply: YHISTORY:Transitioning to VNG diet Recheck  anal sacs (recent burst R anal sacculitis) PREEXISTING CONDITIONS: GR3 Laryngeal collapse (DX at TAHMU) Hyoplastic trachea and tracheal collapse BOAS surgery performed at TAHMUAnxiety Dental diseaseMCT excision base of L ear at WAVEsCURRENT MEDICATION : Fluoxetine 10mg SID, Trazodone 50-75mg PRNPE:T-Not takenHR/CARDIAC-No murmur NSR  HR90/mRR/RESP-Normal lung sounds and respiratory effort. Laryngeal stridor when stressed but quiet today MM-NCRT-NLNN-NABD-NBCS-5.2/9 wt loss of 100gOTOSCOPY/EARS: Allowed otoscopy todayMild debris present inner pinnae. No reported aural pain/pruritus. Vert/hrz canals wnl. ORAL HEALTH: Gr 1-2 calculus L maxill arcadeGr2 calculus R maxill arcade with marginal gingivitis - sl improvedEYES: NMSK: NINTEGUMENT:  Rectal L anal sac : approx 7-8mm in size, firm, containing small vol of inspissated gritty toothpaste like secretionsR anal sac : Approx 4-5mm in size, firm/sl fibrotic,  empty and no content to express. UROGENITAL: NCNS: Not routinely examinedPROBLEM LIST:1. Burst R anal sac abscess - resolved2. Inspissated content L anal sac, sl fibrotic R  anal sac3. Dental disease4. BOAS - GR3 Laryngeal collapse/hypoplastic trachea and tracheal collapse 5. AnxietyRX:Continue with Fluoextine 10mg SID ongoingTrazodone 50mg PRN Continue with nutritional plan from VNGRecheck anal sacs in 2mths    Vital Signs    Weight: 9.1;