C10005542 / invoice 10000

945am 
Marte- has red eye for a few weeks. Seems fine otherwise
Both due for vacc

Consultation -

4 week hx of redness around eye

Subjective:
Seen for :
-
- EDDU normally, no V/D
- no current medications
- BAR on examination
- preventatives ngs

Objective:
T , PR , RR , MM pink, CRT <2s
Body condition:
Thoracic auscultation: No murmur or arrythmia, respiratory rate and effort WNLs, no adventitial sounds.
Abdominal palpation: Soft and non-painful, no distension or fluid wave
Eyes: Clear, no discharge. Pupils even with normal PLRs and menace.
R eye globe NAD, moderate periocular erythema and alopecia
L eye NAD mostly but mild periocular erythema present
Ears: Clean with no discharge or erythema.
Mouth: Grade 1 calculus, grade 1 gingivitis
Integument: Healthy haircoat, no lesions or masses
Musculoskeletal: Ambulatory with no lameness
Neurological: BAR, cranial nerves WNLs
Rectal exam: Not performed

fluo stain neg bilat

Assessment:

Differential diagnoses:

Tx:
chlorasone topically over eyelids both eyes
iramine 4mg PO BID for 3-5 days

vaccinated intranasal KC today

Plan:
recheck eyes in 1-2 weeks, sooner if any concerns
photos taken today for comparison at next visit
adv ecollar to prevent further self trauma 

Bloods last performed:

Dental recommendation:

Focus for next visit:

Next point of contact: