C10009542 / invoice 10000

Reason: Ear InfectionAppointment Notes: Special payment terms exist, Overdue remindersHistory: O thinks he has an ear infection. Has a lot of discharge in R ear. Itching, licking and very bothered by it. Won't let O look. EDDU normal. No c/s/v/d. Resource guards really badly. Will attack fam and pets. Meds: ne zactin SID, catapress AM/PM, Up all night. QOL of those around him still a consideration, will further discuss behaviour with O at next appt. Examine:Limited exam due to behaviour, was very sweet in consult but O didnt want to push him happy to do the basics. Demeanour: BAR. BCS: 5/9Temp: Not taken.CVS: HR not taken. Resp: normal rate and effort. Normal BV sounds. No nasal discharge. Lymph: superficial LNs WNL. Oral: Not assessed - muzzle on. Eyes/integ: NAD. Ears: L) ear NAD. R) ear: mild errythema of pinna, mild brown waxy discharge present. Otoscopic exam not tolerated. Neuro: normal mentation and gait. Full neuro exam not performed. MSK: normal ambulation, no lameness present. Full MSK exam not performed. Cytology: R) ear: 2+ yeast, 1+ cocci. Assessment: Otitis externa of the R ear. Treatment: BNT 3ml R) ear. Plan: WIll come back in 7days for BNT. Will do some more research into behaviour and potential options and rediscuss with O then.    Vital Signs    Weight: 15;