C10010860 / invoice 10000

Reason: Burst blood vessel L eye 

History
O was out on walk with sadie on saturday, grabbed something (O did not see what) and seemed to be choking & coughing lots- O tried to get it but then was gone & Sadie seemed ok. Shortly after O noticed around her L eye was very red- suspects from choking
No blepharospasm or pain since then
Normal self still
EUDD as normal
No known trauma to eye
Was walking in schoolgrounds- not in grass etc 
No V+ 
No signs of choking/FB etc 

Examination
BAR in consult, lovely pup
Oral exam NAD
Cardiac auscultation NAD, NMA
Very comfortable on abdo palp
L eye: Scera inflamed & haemorrhagic. No changes to cornea, no blepharospasm or corneal lesions. Fluroescein negative. Attempted alcaine & FB check but not possible. Attempted IOP but very limited due to age/very wriggly. One reading L eye- 12. 
R eye NAD
2nd opinion vet 12. Elected trial short course BID maxidex to reduce inflammation. Monitor for signs of FB/cause of choking. 

Treatment
Maxidex 1 drop BID L eye

Plan
Very close monitoring
Any change in appearance of eye/squinting etc stop drops immediately & revisit
Revisit friday if not resolved
Monitor for signs of FB (V+, inappetance, toileting etc) 
 

Health Check &final  Vaccinate puppy   

This record was created with the assistance of VetNotes.ai with the client/attendee's permission. 
Record checked/verified for accuracy & relevance by Attending Veterinarian ? - yes

HISTORY:  
Puppy growing well, weight increased 1.5x from 4 weeks ago, now 9.1kg
Owner concerns: concerns about interactions with household cats - she is annoying them

EXAMINATION:
Eyes: nad
Ears: nad
mm:  pink/moist, CRT<2sec.
Teeth:  has some adult incisors - good alignment
Cardiac auscultation:  normal R/R/S
Pulmonary auscultation:  wnl
Abdominal palpation: nad
Lymph nodes:    wnl
hooded vulva
Hernias? - no

BCS: 4  /9
FAS score 0-5:  -- 0 /5  --  calm during examination, responsive to training, not overly excited

ASSESSMENT:  Fit to vaccinate  

PLAN:  

Discuss breed specific issues:   , intelligent and trainable breed
 with positive reinforcement
FAS what worked well?  - calm temperament during handling and training
 - yelped during inj and daughter got a fright and very upset
 and had to cut consult short for o to manage that
Vaccination given:  protech C4 sc while eating treats
Recommended age of desexing:  12-15 months, can be done after first season as will help vulva devt

- Owner taught puppy to sit and drop commands
- Advised on cat-puppy interactions: ensure cats have escape routes, baby gates for separation, watch for eye injuries from cat scratches
- Puppy booklet needs to be signed to complete puppy course - o will go home and get it and come back for parasite Tx as daughter very upset in clinic

- signed vacc book later in morning

Health Check & vaccinate puppy

HISTORY:
Owner concerns: ()
Diet: (Puppy dry Optimum bid..advise go tid)
Previous vaccinations:(C3) 
Current parasite program: (flea only.. o a bit unure ..uncl bob something)

EXAMINATION:
eyes:(n)
ears:(n)
mm:(n)  
teeth:(n)
other oral exam: (n) 
cardiac auscultation:()
pulmonary auscultation:(nn)
femoral pulses:(n) 
abdominal palpation: (n)
lymph nodes:(n)

hips/ortolani sign: (neg)
stifle exam including patellas: (n)
hernias? (n)
BCS:(5) 
FAS score 0-5:(0)

ASSESSMENT:(Healthy and well)
 
PLAN:
recommended parasite program: (mthly NGS or advocate and tape)
discuss breed specific issues: (joints/skin)
FAS what worked well? (treats)
(C5 oral) Vaccination given
Next Vaccination due:(4 weeks)

Discussed Puppy School(y can't do)
Discussed Pet Insurance (y, o will get)
Recommended age of desexing (12-15 m)