C10001113 / invoice 10000

Reason: EarsAppointment Notes: Overdue remindersHistory: Annabelle presents today for suspect otitis externa. Annabelle has been head shaking & pruritic over the past few days. She's otherwise been well, EDDU normally, with no vomiting or diarrhoea Examination: T: DNT           MM: pink & moistP: 108 bpm      CRT: 1-2s R: pantingDemeanour: BAR Hydration: euhydratedWeight: 72 kg (static)BCS: 6/9MCS: 3/3Cardiovascular: no murmur auscultated, normal rhythm, SSFPRespiratory: normal bronchovesicular sounds bilaterally, normal effortAbdomen: soft & comfortable on palpationPeripheral LNs: WNLOcular: clear & bright, no evidence of blepharospasm or sclerititsEars: - AU: mild erythema, moderate brown cerumenous discharge- not tolerant of otoscopic exam Integument: clean healthy coatOral exam: periodontal disease 0/4Musculoskeletal: deferredGait: no overt gait abnormalitiesNeurological: mentation appropriate, full exam deferredRectal: deferredLaboratory: Cytology: - AU: mild malassezia ~10/hpf Assessment: Bilateral otitis externa (malassezia)Treatment: Clean ears bilaterally with epioticOsurnia instilled AUPrednisolone 20mg PO SID q5dGabapentin 1200mg PO prior to appointment Consent has been given by the client to proceed with this treatment  -  YesPlan:2nd Osurnia in 1 week    Vital Signs    Weight: 72;