C09997038 / invoice 10000

Reason: Sore Eye Sf Appointment Notes: Overdue remindersVeterinarian Name: XTL Sienna History: Presented by male and female owner for acute OS blepharospasm after recent grooming. Otherwise EDDU well, no other concerns. Examination: COAT/SKIN: good coat condition, no evidence of external parasites or pruritis, no alopecia EYES/EARS: corneas clear bilaterally, no blepharospasm or discharge present, normal menace response and palpebral reflexes, no scleral injection present; ears clear bilaterally, no malodour or dischargeNOSE: no abnormalities of the nasal planum; no discharge present ORAL: no ulcers, masses or lesions detected; mild generalised calculus present, minimal gingivitis, dental grade 1/4HEART: grade 3/6 systolic heart murmur, no arrythmias detected, normal rate and rhythm, ssfp LUNGS: clear bronchovesicular sounds bilaterally; no crackles or wheezes, normal resp rate and effortABDOMEN: soft, pliable, nonpainful abdomen palpation CNS/MUSCULOSKELETAL: ambulating well in consult room, WBx4, normal gait, no pain, heat or swelling on joint palpation;  BAR, normal mentation, no evidence of CN deficits, full MSK/ neuro exam not performed LYMPH NODES: symmetrical, normal shape and sizeDiagnosis: OS blepharospasm after recent grooming. DDx corneal ulcer vs bactrial conjunctivitis vs FB vs allergy Treatment: Plan:History:Worming/Heartworm/Flea control status:Vaccination status:Nutrition:Examination:COAT/SKIN:EYES/EARS: MOUTH/TEETH:HEART: LUNGS: ABDOMEN/DIGESTIVE/URINARY: CNS/MUSCULOSKELETAL: PERIPHERAL LYMPH NODES: WEIGHT/DIET: Body Condition Score:REPRODUCTIVE: Assessment:Laboratory:  Treatment:Plan:    Vital Signs    Weight: 8.7;