C09994381 / invoice 10000

Reason: Poss Ear Infection + CytopointClient Present:Nurse:WvVaccination: unsurePreventions:current - does at home regDiet:Current meds & doses:Was HPP discussed? Y / NInsurance: Y / N  if yes, Gaponly claim required today? Y / NClient requests +/- concerns:Additional nurse notes:__________________________________________________________________________History: Her ears have flared again - noticed a day after the groomers. Noticed a smell, and started to scratch at themLast ear infection - cleared well with medsNo change in appetite or demeanorExamination: Mental State: normalEyes: both erythemic and small amount of brown discharge present, both smellyEars: normalTeeth: Level 0.5Mucous membranes: pink External Lymph nodes: normalHeart sounds: normal, no murmurs or arrhythmias auscultatedLung sounds: normal BV sounds both sidesAbdominal palpation: comfortable, no abnormalities palpatedSkin: normalGenitals: normal, full GU exam not performedMusculoskeletal: ambulatory x4, no deficits noted in consult, full MSK exam not performedNeurological: BAR, no deficits noted, full neuro exam not performedTemperature: not takenLaboratory: malassezia +++ both earsAssessment: Otitis externaConsent has been given by the client to proceed with this treatment  -  YesPlan: Ears cleaned and results discussed with O - O happy to medicate at home. To apply surolan 1ml BID for 7 days, recheck in 10 days. First tx instilled in clinicCytopoint 30mg given SQDiscussed maintenance ear cleaner with otoflush/ dexapent mix or cortavance twice a week to reduce aural inflammationRecommend weight loss - reduce food intake and recheck weight in 6-8 weeks to be able to palpate ribs better and have more tucked tummy    Vital Signs    Weight: 18.5;