C09971013 / invoice 10000

HISTORY
- Vet: Vicky Wade
- Presenting complaint: Presented on 16/02/2026 AEST. Ongoing conjunctival discharge and inflammation of the eyes. Patient is fearful and anxious in the clinic environment.
- Weight change since last visit: Not specified.
- Current medications: Ocular drops (frequency not specified, withhold prior to exam per owner report).
- Client concerns:
  - Concern about conjunctival discharge, particularly in the mornings.
  - Happy with significant improvement since commencement of treatment; discharge now localised and minimal; resolved weeping.
  - Noted improved patient demeanour and activity (more interactive, jumping on furniture).

FOCUSED PHYSICAL EXAM
- Patient anxious and fearful during exam; examination adapted (no lights used on eyes due to fear response).
- Persistent mild conjunctival hyperaemia noted bilaterally.
- Small amount of discharge remains at medial canthus, especially visible on eyelid manipulation; improvement from previous extent.
- Drain site associated with a Jackson-Pratt drain is clean, with no discharge; drain secured with sutures, not interfering with patient comfort or causing external soiling.
- No additional abnormalities noted.

DIAGNOSTICS
- Bilateral conjunctival cytologies performed.
- Results: Both cytology samples unremarkable—no indication of active infection.

ASSESSMENT
- Persistent mild conjunctivitis with marked clinical improvement.
- Ocular discharge substantially reduced.
- No evidence of ongoing infection on cytology.
- Drain site healing as expected.

TREATMENT
- Continue ocular drops: one drop in each affected eye, twice daily for two weeks.
- Revisit scheduled for reassessment post-treatment.

COMMS
- No treatments declined by the owner.