C10015683 / invoice 10000

Appointment Notes: jade 0413761356 - konan - Ear concernsScratching at his ear, seems irritatedHISTORY:scratching left ear for 2 weeks. no previous medical concernsCurrent Medications: None Medical conditions: None Vomiting or diarrhoea: None Any Concerns: None Diet: woolsworth dry food and coles. Appetite and thirst: NormalFlea/tick: NGSWorming: NGSEXAMINATION: Demeanour: BAR MM: Pink, moist, CRT <2 Eyes: Clean and clear, normal eyelids, no erythema or discharge Ears: rigth ear minimal debris, no inflammation or odour. left ear erythemic and moderate amount of brown discharge on inside of pinna. ear canals clear with intact healthy TMLymph nodes: Peripheral lymph nodes palpably normal Oral: No oral lesions or abnormalities detectedTeeth: Dental grade 1/4, normal occlusion. COHAT Level Estimated: (A)Cardiovascular: Normal heart sounds, no murmurs or arrhythmias detected, femoral pulses synchronous and normodynamic Respiratory: No nasal discharge, normal bronchovesicular lung sounds in all 4 quadrants, no coughing seen Abdomen: Soft and comfortable on palpation, no masses palpated, bladder unremarkable MSK: Normal gait no lameness. Normal ROM with no pain of all limbs. No pain on DV palpation of spine Integument: Coat is soft and clean, no ectoparasites detected, no obvious skin lesions or masses Neurological: Normal mentation, no ataxia or CP deficits observed. Full exam not performed Reproductive/Urogenital: External genitalia normal in appearance Rectal: Not performed BCS 6-7/9PROBLEM LIST: left otitis externaoverweightDIAGNOSTICS: left ear cytology - moderate numbers malassesiaASSESSMENT/DDX: PLAN:dermotic 1ml BID in left ear for 10 days. recheck in 10 daysrecommend weight loss. aim for 59kg and reassess. may still need to lose more and be 55kg. but start with 59kg. aim for 1-2% weight loss a week. MEDICATION: CLIENT COMMUNICATION: N/A TREATMENT: Handouts given: Health report / Dental / Arthritis / Other (Name)Estimate provided (Y/N or NA)    Vital Signs    Weight: 65;