C10010394 / invoice 10000

SubjectivePresenting Concerns:-   Irritation and dark discharge in the AS for 2 days.  Historical Conditions:-   History of food allergies causing pododermatitis.  Diet/Appetite:-   Fed a Royal Canin Hypoallergenic diet. Recent dietary indiscretion is suspected due to grandchildren dropping food.  Lifestyle Risk Factors:-   Weekly contact with young children.ObjectiveMentation: BAR  Wt: —  BCS: --/9  T: Not taken  P: —  R: —  MM: pink/moist. CRT < 2sec.  Hydration: Normal    Emotional Assessment: —    Eyes: Clear. No discharge or erythema OU.  Ears: Mild inflammation of the AS canal. AD appears normal.  Nose: Clear, moist without discharge.  Throat: No inducible cough upon tracheal palpation; no palpable masses.  Oral: Calculus and gingivitis absent. No masses or other lesions.  Cardiovascular: No murmurs or arrhythmias, strong synchronous pulses.  Respiratory: Normal bronchovesicular sounds bilaterally.  Abdominal: No organomegaly or mass effects. No pain on palpation.  Lymph Nodes: No peripheral lymphadenopathy.  Integumentary: No evidence of ectoparasites, full coat with clear skin.  Neurologic: No ataxia, normal mentation.  Musculoskeletal: Ambulation normal, no lameness observed.  Urogenital: Normal external anatomy.  Rectal: Not performed.    Point of Care Diagnostics:-   Ear Cytology (Left): No yeast or bacteria identified.AssessmentAllergic Otitis Externa - Mild inflammation of the AS consistent with a flare-up of underlying food allergies. Cytology revealed no infectious organisms.PlanMedications/Treatments:-   Steroid ear drops: Apply 2-3 drops into AU once weekly.  Diet & Feeding Recommendations:-   Strictly continue the Royal Canin Hypoallergenic diet.-   Advised to prevent access to other food sources.    Vital Signs    Weight: 10.4;