C10022294 / invoice 10000

Reason: Eye Infection ?  BBAppointment Notes: Overdue remindersHISTORY:  Presented for a red eye for the last 3 days. The owner reports that the dog's eyes are often red after grooming appointments. But grooming was done 2 weeks ago.Not rubbing eyes. Is squinting and d/c  Grade 3-4/6 left-sided systolic heart murmur identified on auscultation. The owner was counselled on the significance of the murmur, its association with the patient's breed (Cavalier cross), and the potential for progression to congestive heart failure. The option of a specialist echocardiogram was discussed to assess severity and determine if early medical management is indicated. Current recommendations are to monitor for clinical signs such as coughing, exercise intolerance, or increased respiratory effort.No vomiting or diarrhoea reported. Eating well. Current meds: noneVaccination: Not mentionedParasite Prevention: Not mentionedPre-existing conditions: noneAccess to toxins eg. Rodenticide:none TRIAGE:Demeanour/Behaviour: quiet and calm EXAMINATION:Body Condition Score: 7/9Pain Scale (0-4): 0/4Hydration status (%): hydration clinically adequateCardiovascular: Grade 3-4/6 left apical systolic heart murmur.Respiratory:thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological:neurologically no significant findingsMusculoskeletal: ambulating normallyGastrointestinal:Oral: normal, no mouth pain, dental score (1-4):4Abdominal: no detectable pain on abdominal palpationRectal: not performedUrinary: NSFReproductive: NSFIntegument/Ears: NSFLymph Nodes: NSFEyes: Schirmer tear test performed: Left eye 17mm/min, Right eye 16mm/min. Topical local anaesthetic applied. No FB. Fluorescein stain applied to the left eye revealed a 7x4 mm corneal ulcer on lateral mid quadrant. Third eyelid is prominent. Fundus NAD. Scleritis. Conjunctivitis. Globe slightly sunken. Bilateral nuclear sclerosis.  PROBLEM LIST:Left superficial corneal ulcer (7x4 mm)Grade 3-4/6 left apical systolic heart murmur DIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:Left corneal ulcerMitral valve disease secondary to degenerative changes is suspected for the heart murmur. DIAGNOSTICS:Schirmer Tear Test: L eye 17 mm/min, R eye 16 mm/min (Normal).Fluorescein stain (L eye): Positive for a 7x4 mm corneal ulcer. ASSESSMENT:Presented for ocular assessment. Examination revealed a large 7x4 mm corneal ulcer in the left eye. Schirmer tear test was within normal limits, ruling out dry eye as an underlying cause. A significant grade 3-4/6 heart murmur was also incidentally auscultated. The ulcer requires medical management, and the owner has been advised on potential complications, including the possibility of an indolent ulcer requiring surgical intervention if it fails to heal. The heart murmur currently requires monitoring, with specialist referral for echocardiogram discussed as an option for further assessment and management. TREATMENT:  Anti-inflammatory medication (metacam) prescribed for pain and inflammation associated with the corneal ulcer.Topical eye ointment (Chloropt) prescribed to promote healing of the ulcer. PLAN:Continue prescribed medications as directed.Re-evaluation of the left eye in 5-7 days to assess healing of the corneal ulcer.Monitor at home for any signs of worsening ocular irritation, increased discharge, or changes in vision.Monitor for clinical signs associated with the heart murmur, including coughing, exercise intolerance, or changes in breathing. Seek immediate veterinary attention if these signs develop. CLIENT COMMUNICATION:Discussed the diagnosis of a corneal ulcer and the treatment plan. Advised that ulcers in older dogs can be slow to heal, potentially requiring surgical procedures such as a grid keratotomy or tarsorrhaphy if medical management is unsuccessful. Discussed the side effects of anti-inflammatory medication, including the risk of gastrointestinal ulceration.Explained the findings of the heart murmur and the importance of monitoring for signs of congestive heart failure. Discussed the option and benefits of a specialist echocardiogram to guide potential early intervention with medication to slow disease progression. The owner understands the plan and when to seek further care.    Vital Signs    MMColour: p;       Weight: 13.5;       Temperature: 39.0;       BodyScore: 6-7;       DentalGrade: 4;       CRT: <2;