C10020716 / invoice 20000

Diet - home cooked meat and vegetable
Dental Sacale and polish

Pre-medication: Methadone 0.7ml /ACP 0.3ml IM
Anaesthesia: - Alfaxan  3.3ml
IVFT / Total Fluid: 74ml/hr
ET Tube Size:  6.5

Procedure/Grade of teeth: 2/4

Extractions: None
Missing: none
enamel damage in both 108,208

Left ear- mild inflammation . malassezia++++
Right ear, significant swelling, waxy debris, Cytology , malassezia ++
Both ear flushed 

Right ear canal irrigated with saline about 120ml
TM perforated on right

Home medication: Dermotic 0.7ml bid for right for 2weeks
Left 0.5ml bid for 7days ( use old bottle)
Pred X 7.5mg bid for 3days, 7.5mg sid for 4days, then 7.5mg eod

Plan: r/v  14days ear check

Also discuss referral to dermatological to discuss allergy rather than doing blood test  for allergy 

Admit / GA / Dental / Pluck Ears / +/- Ear Clean
Fasted
Insured
Vaccinations upto date
Antibiotics for ears given yesterday
Wife pick up after 5PM
Chicken Allergies
TPR= (CG)
HR = 120
Clear
Mm = Pink
BAR

Reason: 
R ear
History: 
started shaking head and scratching esp at R ear
lots of brown discharge seen when O cleaned
DUDE normal
no other concern
Examination: 
HR:120, panting
Temp: ne
mm: pink
Eyes/Ears:R ear erythema and brown discharge present, L ear erythema and minimal brown discharge present
brown discharge stuck at entrance of R ear canal, wiped with epiotic
cytopogy R ear malassezia + cocci + WBC ++,  L malassezia +
Teeth:n
Abdomen:n
Musculoskeletal:n
Other: n
assessment:
bilateral otitis mainly malassezia
Treatment:
dermotic 0.5ml bid for 2 weeks
Plan: 
RV 2 weeks for recheck/cytology
O will book for dental and wants us to check ears at that time - ear check/clean is not in dental estimate and O understood