C10009348 / invoice 10000

Reason: NPC - Ear Infection (GM)History:Head shaking first noted today. Prev had ear infection in Sept in L ear. EDUD normal. No vomiting or diarrhoea. No lethargy. Examine:Mentation: BAR Demeanour: Good for PE HR: 132, no murmurs or arrhythmias RR: 30, lung fields clear BCS: 6/9Eyes: NAD Ears:- L ear NAD - R ear: ++ brown discharge in ear canals, ear swab cytology showed yeasts and cocci ++, minimal erythema, mild pruritus  Dental score: Grade 1/4 periodontal disease, mild plaque accumulation, minimal gingivitis MM/CRT :  Pink, moist, CRT <2s LN: NAD  Skin/Coat: NAD Fleas seen: N Abdomen: Comfortable on abdominal palpation, gut sounds normal, no organomegaly or masses noted.                       Limbs/Gait: Ambulating well, weight-bearing on all four limbs. Did not do full MSK exam. Assessment:R ear otitis externa - malassezia and staphylococcus - most likely underlying allergic etiology (ddx atopic dermatitis vs food allergy) Requesting once off treatment as unable to administer ear medication at home Treatment: Mometamax ultra in R ear Plan: Return if concerned/ not improving. Keep ears dry.  Estimates given for any procedures discussed.Consent forms signed for all admissions/procedures.    Vital Signs    Weight: 10.3;