C10023440 / invoice 10000

REASON: Ocular examination.HISTORY:- Presented for a general health assessment and specific examination of the eyes. Was squinting and eyes seemed sore this morning, had a previous similar episide 12m ago- The owner reports no other concerns.- EDUF WNL.- Current medications: apoquel. Recently restarted due to allergiesEXAMINATION:Friendly and cooperative for the examination.Dental/Oral: MM pink, moist, CRT<2s, dental grade 1/4Ocular: L eye mildly inflamed conjunctiva, serous discharge. Fluorescein stain applied. No stain uptake was noted, indicating no corneal ulceration. R eye normalOtic: ears clean and healthyCardiovascular: Heart sounds normal, rate and rhythm appropriate, pulses strong and synchronous.Lymph Nodes: all peripheral LNs WNLsRespiratory: Lung sounds normal, no adventitious sounds, normal respiratory rate and effortGastrointestinal:- Abdominal: relaxed and comfortable, normal gut sounds- Rectal: not performedUrogenital: normal, no abnormalities notedIntegument: Skin normal, no erythema. Coat normal, no alopecia. Normal skin tentsMusculoskeletal: grossly normalNeurological: no obvious neurological deficitsTemperature: temperature not taken to facilitate positive experienceDIAGNOSTICS:Nil performed.Problem List:1. Mild unilateral conjunctivitis- Assessment: Based on the clinical examination showing mild inflammation without corneal ulceration.- Treatment plan: chlorasone for a few days.ASSESSMENT:A general health check was performed. The main finding was mild, unilateral ocular inflammation. A fluorescein stain test was negative for any corneal scratches or ulcers. TREATMENT:- chlorasone for 5-7d.PLAN:- Discuss treatment options for mild conjunctivitis.- Monitor for any changes in the ocular signs.- Re-present if any concerns.CC 3d    Vital Signs    MMColour: pink moist;       HeartRate: 120;       BodyScore: 3/5;       DentalGrade: 1/4;       RespirationRate: WNLS;       CRT: <2s;