C10000833 / invoice 10000

Reason: Ear IssueAppointment Notes: evReason: History:Presenting for: Patient presented for ear examination and treatmentLifestyle Risk Factors:- Does not go swimming, afraid of waterExamination:Behavioural: Patient exhibits frequent body shaking behaviour, though not pruriticEars: Left ear examination revealed Malassezia overgrowth. Otoscopic examination limited due to patient discomfort - unable to visualise tympanic membrane clearly. No obvious foreign body identified. Right ear normal.Diagnostics: Ear cytology - Malassezia overgrowth noted at approximately 10 organisms/hpf (normal <3/hpf), consistent with yeast overgrowth/dysbiosisAssessment:Otitis externa (left ear) - Malassezia overgrowth secondary to dysbiosisPlan:New Meds/Tx:- Ear drops prescribed for left ear BID for 7 days. Instill drops as far down the vertical canal as possible, massage, then clean excess to prevent wax accumulationAdditional Discussion:- Recheck appointment scheduled for day 8-9 post-treatment to assess response and complete otoscopic examination when ear less painful- Advised to prevent patient from shaking head immediately after drop application to ensure adequate contact timeHistory: Current Medications:Senior: discuss if needed.Vaccinations up to date ? Examine: Diet: Dental/oral cavity: Eyes: Ears: Cardiovascular/respiratory: GIT/abdomen: Urogenital: M/skeletal: Skin: Lumps: Lymph Nodes: Behaviour: Assessment: Treatment: Plan: Script status:  Checked and updated? Yes/NoVaccination / Blood test / Catrophen Reminders up to date? ADJUST ACCORDINGLYRevist/ Recall/ Reminder:History:  Examine: Assessment: Treatment: Plan: Revist/ Recall/ Reminder:    Vital Signs