C10021613 / invoice 10000

H: itchy again since last monthskin was good through autumn and winterhans't noticed any issues with earsutd advantageotherwise well, edud normal, no v/d, c/sE: BAR, BCS 5/9Eyes nose nsfMMs pink, moistR ear canal bit dirty dark waxy dcL ear +++ dark waxy dxear swab and cytologyR ear nsf, squames but no sig infectious agentsL ear +++ yeastboth ears flushed otoflushHR 100, no murmurLungs clearintegumentscratching at body ++ in consultA: L ear yeast OEallergic skin diseaseP: 1ml cytopoint 40mg SC1ml dermotic BID to L ear for 2 weeks then revisitO to continue otoflush clean L ear twice weekly until revisitprotech C4 vacc SC, oral bb1.5ml afilaria SC

itching again a bit scabby at neck - O said the previous collar has been rusted recc medicated shampoo wash EOD 

H: has become itchy in past 4 weeksoften gets itchy this time of yearscratching mostly chest, axilla areaotherwise well, edud normal, no v/d, c/sO says gets monthly advance? parasite spot on treatment? not sure if advantage or advocatewants hw injection today anyway to be safeprevious hx ear infectionsE: very BAR, BCS 5/9Eyes - mild scleral hyperaemia both eyesR eye mild clear mucoid dcmild alopecia around both eyesEarsboth chronically inflamed, thickened, strong yeast smell+++ black waxy dccleaned with otoflushHR 100, no murmurLungs clearabdo snfTemp 39.6 but very excited, jumping aroundintegumentskin bit pink and chronically thickenedno obvious hotspots or areas of significant dermatitis seenscratching in consult ++A: likely atopic dermatitisokay for vaccP: C4 vacc SCoral bb1.5ml afilaria SCstart cytopoint injections, 1ml cytopoint 30mg SCdermotic bid both ears for 2 weeksotoflush q1-2 weekly ongoing