C09999567 / invoice 10000

Reason: Eye ProblemClient Present:peterNurse:WvVaccination:poss done elewherePreventions: exlpet? Thinks it does everythingDiet:Current meds & doses:Was HPP discussed? Y / NInsurance: Y / N  if yes, Gaponly claim required today? Y / NClient requests +/- concerns:Additional nurse notes:__________________________________________________________________________HISTORY:  Presenting complaint is a weeping right eye, which started this morning. The owner reports Milly has been 'funny with her food'. She is an anxious dog and has recently commenced alprazolam for anxiety. Otherwise, has been well. Current meds: alprazolam for anxiety.Pre-existing conditions: Anxiety.Access to toxins eg. Rodenticide: none TRIAGE:HR: 120 bpmRR: PantingTemp: 38.2 degrees celciusMm:  PinkCrt: 1-2 secondsMentation: Bright, alert and responsive.Demeanour/Behaviour: not discussed EXAMINATION:Body Condition Score: 5/9Pain Scale (0-4): 1/4Hydration status (%): hydration clinically adequateCardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory:thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological:neurologically no significant findingsMusculoskeletal: ambulating normally, no palpable neck, spine, limb or joint painGastrointestinal:Oral: normal, no mouth pain, dental score (1-4):grade 2Abdominal: no detectable pain on abdominal palpationRectal: not performedUrinary: NSFReproductive: NSFIntegument/Ears: NSFLymph Nodes: NSFEyes: Right eye (OD) has serous ocular discharge. The sclera and conjunctiva are hyperemic with mild chemosis. The left eye (OS) is normal.Demeanour/Behaviour: not discussed PROBLEM LIST:1. Right ocular discharge2. Right conjunctival and scleral hyperaemia3. Mild right chemosis4. Anxiety5. Dental disease (Grade 2) DIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:Right-sided conjunctivitis. DIAGNOSTICS:A fluorescein stain was performed on the right eye, which was negative for corneal ulceration. ASSESSMENT:Milly presented for an acute onset of right-sided ocular discharge. Examination revealed signs consistent with conjunctivitis, including hyperaemia and mild chemosis. A fluorescein stain was negative, ruling out a corneal ulcer. The clinical diagnosis is conjunctivitis of the right eye. TREATMENT:  Amacin eye drops, to be applied to the right eye twice daily for five days. PLAN:Home into owner's care.Re-evaluation is recommended if the eye has not improved within 48-72 hours. CLIENT COMMUNICATION:Discussed the diagnosis of conjunctivitis and the treatment plan. Advised on the administration of eye drops. Instructed the owner to return for a recheck if the condition does not improve or worsens over the next 2-3 days.    Vital Signs    Weight: 20.6;