C10005505 / invoice 10000

Reason: EyesAppointment Notes: Overdue remindersHISTORY:  Presented for assessment of ocular discharge and red spots on both eyes, present for the last two weeks. The owner has been wiping the eyes. The left eye has a more prominent red spot. The right eye had a similar appearance yesterday. Squinting is noted. The owner has been cleaning the eyes with warm soapy water.There has also been a snotty nose recently. There is a history of sneezing, typical for the breed, but no coughing. Stenotic nares are noted. Current meds: noneVaccination: Not mentionedParasite Prevention: Not mentionedPre-existing conditions: Stenotic nares.Access to toxins eg. Rodenticide: none EXAMINATION:Body Condition Score: 5/9Pain Scale (0-4): 0/4Hydration status (%): hydration clinically adequateCardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: Stenotic nares noted with some nasal discharge (crusting). Thoracic auscultation clear sounds bilaterally, respiratory effort normal.Neurological: neurologically no significant findingsMusculoskeletal: ambulating normally, no palpable neck, spine, limb or joint painGastrointestinal:- Oral: normal, no mouth pain, dental score (1-4): not graded- Abdominal: no detectable pain on abdominal palpation- Rectal: not performedUrinary: NSFReproductive: NSFIntegument/Ears: NSFLymph Nodes: NSFEyes: Granulation tissue present on the left eye. The right eye appears to be in a more advanced stage of healing with some residual corneal oedema. Lesions are located in the medial canthus area, approximately 4-5 mm on both sides. Epiphora is present. Fluorescein stain applied to the eyes showed no stain uptake. A Schirmer tear test was discussed but not performed.Demeanour/Behaviour: Anxious in the consult room. PROBLEM LIST:- Bilateral corneal lesions (granulation tissue)- Epiphora- Mucoid nasal discharge- Stenotic nares DIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:Corneal ulceration/injury with secondary granulation tissue formation. DIAGNOSTICS:Fluorescein staining of both eyes: Negative for stain uptake. ASSESSMENT:  Murphy presented for bilateral ocular changes. Examination revealed granulation tissue on both corneas, more pronounced on the left. The negative fluorescein stain suggests the initial ulcers have epithelialised. The nasal discharge is likely secondary to epiphora draining via the nasolacrimal ducts, exacerbated by stenotic nares. The options of conservative management versus debridement were considered. TREATMENT:  Triacin eye ointment to be applied to both eyes, 2-3 times daily. PLAN:Re-evaluation in 5-7 days. If the condition worsens, return for an earlier reassessment. Continue home care under the owner's care.History: Examination: Laboratory: Assessment: Treatment: Consent has been given by the client to proceed with this treatment  -  Yes/No Plan:Reason: Nurse: -vaccination -heartworm -worming -flea/ticks Exam: Lab: Assessment: Treatment: Plan:    Vital Signs    Weight: 15.4;