C09996411 / invoice 10000

Reason: right ear infection- Ear scratching noted this morning, started suddenly- Toe swelling on outside toe of back paw - owner suspected possible infection- Frequent paw licking reported- No previous ear complaints- No previous itchy skin issues reportedPhysical Exam: BAR, mms pink and moist, CRT <2 secCardiovascular: no murmurs or arrhythmias detected, lung fields clear Gastrointestinal: abdominal palpation soft, comfortable, no organomegaly or mass lesions palpatedMusculoskeletal: normal gait, manipulation of extremities unremarkableIntegument: no gross lesions, normal coat Ears: unremarkable- no erythema or exudateEyes/mouth/nose: unremarkableNeurological: appropriate mentation- Right ear: unable to visualise tympanic membrane, significant yellow purulent discharge present, ears very sore- Ear cytology: ++ malassezia scant degenerate WBC Assessment & Plan:1. Otitis externa - fungal (yeast)- Ear cleaning performed in clinic- Long-acting ear treatment applied (lasts one month)- Advised to avoid swimming- Recheck in 3-4 weeks to assess resolution- Repeat treatment may be required if residual infection present2. Toe swelling- Examined, appears unremarkable- Not considered a significant concern at this timeHistory:Presenting problem:Diet:Preventatives:Examine:BAR, mms pink and moist, CRT <2 secCardiovascular: no murmurs or arrhythmias detected, lung fields clear Gastrointestinal: abdominal palpation soft, comfortable, no organomegaly or mass lesions palpatedMusculoskeletal: normal gait, manipulation of extremities unremarkableIntegument: no gross lesions, normal coat Ears: unremarkable- no erythema or exudateEyes/mouth/nose: unremarkableNeurological: appropriate mentation, no cranial nerve deficits, spinal painProblem list:Options:Discussion:Treatment:Plan:    Vital Signs    Weight: 4.5;