C10002934 / invoice 10000

HISTORY: Presented for: Sore R ear, otherwise well
EDDU: normal
Vomiting/diarrhoea: none
Coughing/sneezing: none
PU/PD: none
Current meds: none

Physical exam:
BCS:  7/9
Demeanor: BAR
Oral: crt<2s, mm pink and moist, grade 2/4 periodontal disease, no intraoral lesion or foreign body
Eyes: no evidence of ocular disease
Ears: Brown discharge and erythema in R ear
Cardiovascular: HR100-SR, no murmur, FP s/s
Respiratory: RR<30, normal respiratory rate and effort, normal lung sounds on all fields, normal laryngeal/tracheal auscultation. No spontaneous cough/sensitivity on tracheal palpation.
Abdomen: comfortable/no abdominal guarding, non-distended, no obvious masses
Integument: coat excellent
Musculoskeletal: unremarkable, no evidence of lameness, limbs palpate normally, normal ROM on C-spine and hips, no pain across cervical/lumbar spinal palpation or tail
Neurological: unremarkable
Lymph nodes: no palpable peripheral lymphadenopathy
Rectal: not assessed

Diagnostics:
R ear cytology: yeast

Assessment:
R otitis externa with malassezia

Treatment:
Cleaned R ear with otoflush
Apex PMP BID for 7 days

Plan:
Recheck ear + cytology in 7 days
WRMRQ: N
FLRQ: N
WEIGHT: 22.80
DENTAL: 2
BODY: 7