C10019411 / invoice 10000

Appointment Reason: Recheck, Appointment Notes: ?CG????History: Recheck consultation for an eye condition and known heart murmur. The owner reports the eye appears less red than it did last week. Maya is eating and sleeping well, with no other changes noted. She is currently on a steroid eye cream which the owner has been able to administer despite her being head shy. The owner reports Maya gets stressed by the e-collar. The owner enquired if Maya could go swimming in the creek.Exam:Demeanour: BAREyes: Right eye appears open and comfortable. No epiphora or ocular discharge noted. Corneal/scleral vascularity is still present but appears less prominent than previous examination. See attached picture. Left eye nad.Ears: Vertical ear canals clear, full otoscopic/aural exam not performed todayOral: MM pink, moist. CRT <2sNose: Nares clear, no dischargePeripheral lymph nodes: No peripheral lymph node enlargement palpatedCardiovascular: Grade 2-3/6 heart murmur. Normal rate and rhythm. Respiratory, breathing: Normal bronchovesicular sounds on auscultation. No crackles/wheezes.Skin: clear coat, no evidence of ectoparasites or dermatitisAbdomen: Soft and comfortable abdominal palpation. No large masses or organomegaly identifiedNeurological: Navigating waiting room and consult room well. Full neurological examination not performed.Musculoskeletal: Ambulating well around consult room. Full MSK examination not performed.BCS: 6/9Assessment:* Ocular condition: Improvement noted in the degree of vascularity. Condition is responding to topical steroid therapy.* Cardiac: Known heart murmur remains static on auscultation.Client Communications: Discussed the improvement in Maya's eye and the plan to continue treatment. Advised that the heart murmur is currently unchanged and to monitor for any signs of exercise intolerance, such as slowing down on walks. Advised that swimming is permitted, but to cease this activity if it causes eye irritation.Treatment:* Continue steroid eye cream/drops for a further two weeks.* E-collar removed.Plan: Recheck in two weeks if the eye is still red. If the eye appears normal after the course of treatment, no further recheck is required. Return sooner if any squinting or ocular discharge develops. The client can call to arrange collection of more chloroptsone if required.12/03/2026 8:31:26 AM CG:F/up SMS sent?????    Vital Signs    Weight: 33.5;