C10008798 / invoice 10000

Reason: Ear Infection RMHistory:Shaking head started 3 days ago. Has not had ear infections beforeTook to groomer yesterday, checked ears and said one very red (L side)EDUD normal, no V+/D+No current medicationsExamination:BAR , very nervous in consultMM pink and moist, CRT <2 sec HR 156 bpm, no murmur or arrhythmia detected RR WNL, chest clear Abdominal palpation NAD Ears-              Appearance: L ear very red and large amount waxy brown discharge-              Otoscope exam: Unable to scope as patient very sore and anxious-              Cytology: L ear yeast ++, neutrophils +, no bacteria. R ear clear on cytologyAssessment:Otitis externa L ear - malassezia. Suspect also inflammation secondary to groomingPlan:Dermotic BID for 7 days, recheck in 10 days    Vital Signs    Weight: 6.7;       

ACP/Methadone PM,Surgery: G/A D/K then Iso/O2. Routine midline spey. 3 layer PDS closure.  tattooMeloxicam Injection on RecoveryHome- strict rest 2-3days, oral Meloxicam.    Vital Signs    

Reason: Annual Vax & GHC JtAppointment Notes: Overdue remindersReason: Vaccination BS Oral and Pi2Has been well, did not fall pregnant last attemptEDFU all OKParasite prevention UTD (O works at ARH)Examination: BAR MM pink and moist crt<2secHR WNL, no murmur detectedRR WNL chest clearDentition goodAbdominal palp NADEyes/ears/nose NADCoat and integument NADMusculoskeletal exam NADWt goodTreatment: Vaccination BS oral and Pi2    Vital Signs    Weight: 6.5;       MMColour: pink;       Temperature: 38.7;       HeartRate: 119;       BodyScore: 4.5/9;       DentalGrade: 0;       RespirationRate: 29;       CRT: 1;