C09997415 / invoice 10000

Ear infection.
14.0

large amount of crud and inflammation down the right ear. Ear infection still present. Has been on PMP for 2 weeks no improvement

Lepto 2 vaccination - booster today and then another in 2 weeks. Needs for conservation work.

Plan:
Otoflush daily for 7days, then twice weekly
Topigen for 10 to 14 days
Recheck ear in 2 weeks. 



Verified: NO

HISTORY
Presenting for: Monty Moore presented for ongoing ear infection that has persisted for the entire year and never fully resolved.
Historical Conditions: Recurrent ear infections - only medical issue that typically affects this patient
Current Meds: Otoflush - has been using but infection persists
Other: Patient insured with Everyday Pet Insurance

EXAM
Ears: Left ear infection confirmed

ASSESSMENT
Otitis externa - chronic/recurrent infection requiring extended treatment course

PLAN
New Meds/Tx:
- Otoflush daily for 7 days, then reduce to twice weekly ongoing
- Recheck ear infection in 2 wks to ensure infection has cleared before discontinuing antibiotics

Vaccinations:
- Lepto vaccination discussed - patient previously received one dose but requires second dose to complete initial series. Two vaccines needed 2-4 wks apart for proper immunity.
- Annual vaccinations may be due - client to confirm vaccination history

Client Comms:
- Insurance claim processed successfully with gap payment arrangement
- Follow-up appointment scheduled in 2 wks for ear recheck

had ear infection previously, recheck to confirm its improving

There is still a large amount of inflammation down the ears.
swab - cocci and fungi

Dispensed PMP BID to both ears

ear infection, smells bad

Right ear - severe infection - ear canal is red with large amount of smelly, pussy debris

Ear swab - bacteria - cocci and rods, WBC, odd fungi

otherwise NAD

Plan - Topigen bid for 10days then recheck ear
owner to clean ear at home with ear cleaner before start drops.