C10006460 / invoice 10000

Recheck eye SubjectivePresenting Concerns:-   Albert, a 1.5-year-old Cavoodle, presented for a recheck of a left corneal ulcer.  Current Medications:-   The patient has been receiving Clausewig eye drops. The owner reports the eye improved soon after starting treatment.  Lifestyle Risk Factors:-   Attends a groomer.-   Was removed from daycare due to pinning other male dogs.  Additional Information:-   The owner reports a history of anxiety and aggression towards other male dogs.ObjectiveMentation: BAR  Wt: —  BCS: --/9  T: Not taken  P: —  R: —  MM: pink/moist. CRT < 2sec.  Hydration: Normal    Emotional Assessment: Anxious during the consultation.    Eyes: Clear. No discharge or erythema OU.  Ears: Clean with no discharge or erythema AU.  Nose: Clear, moist without discharge.  Throat: No inducible cough upon tracheal palpation; no palpable masses.  Oral: Calculus and gingivitis absent. No masses or other lesions.  Cardiovascular: No murmurs or arrhythmias, strong synchronous pulses.  Respiratory: Normal bronchovesicular sounds bilaterally.  Abdominal: No organomegaly or mass effects. No pain on palpation.  Lymph Nodes: No peripheral lymphadenopathy.  Integumentary: No evidence of ectoparasites, full coat with clear skin.  Neurologic: No ataxia, normal mentation.  Musculoskeletal: Ambulation normal, no lameness observed.  Urogenital: Normal external anatomy.  Rectal: Not performed.    Point of Care Diagnostics:-   Fluorescein stain (left eye): Negative.AssessmentCorneal ulcer (left eye) - Resolved.    Anxiety with inter-dog aggression - History of pinning other male dogs. Referral to a veterinary behaviourist is recommended for assessment and management.PlanMedications/Treatments:-   Continue Clausewig eye drops in the left eye twice daily for 4 days, then discontinue.  Additional Discussion:-   Information for veterinary behaviour specialists (Calm Pets and Animal Sense) was emailed to the owner to address anxiety.-   The owner reports that vaccinations are up to date.    Vital Signs