C10029160 / invoice 10000

REVISIT

REASON: Recheck eye
PROGRESS: Less discharge.  
EXAM: Conjunctivitis much improved, but still no fluoro at nose.  
May be fully blocked, or may need more time with amacin to help open the duct. 

ASSESSMENT:Tear duct blocked

PLAN:If causing ongoing problems with recurrent infections may need GA to flush ducts.

CONSULT

REASON/CONDITION:
**DATE OF FIRST CLINICAL SIGNS

Nurse notes:

History:
**existing health concerns
- noticed lump on back -dx as a wart - started to grow horns - these have come off and bled when it did 
- just want this checked
- chews a bit at feet also 

Patient Data/exam
TEMPERAMENT: good
BEHAVIOUR/ CC EFFECT: x
WEIGHT/BCS: 8/9
NORMAL DIET:
EDUD?: n
**CURRENT MEDICATIONS/CONDITIONS: none
TEMP: 38.2
HR & SOUNDS / PQ: 120, no murmur
MM COLOUR & CRT: pink, 1 sec 
RR / LUNG SOUNDS: panting 
ABDO PALP: very very tense
RECTAL: x
EENO: L eye - mild to moderate inflammation of conjunctiva with brown ocular discharge. STT 22mm. Fluroscein stain negative. No blepharospasm. No fluroscein stain from L nostril
DENTAL: 0/4 except upper canines and Upper I3 - calculus.
SKIN: Moderate pododermatitis with erythema and dark brown waxy/greasy debris in between toes/pads. Mutiple burrs in coat - clipped off. All nails clipped. 
LNs: n
MSK: n
NEURO: n
UROGEN: n

**Assessment/Problem list:
1. L eye - conjunctivitis with blocked/ non patent nasolarcimal duct. 
2. pododermatitis with yeast infection
3. Mild tartar upper canines only
4. overweight but has lost 800grams recently. 

Tx plan: cytopoint 20mg sc. Bathed all feet in malaseb in clinic

Communication/ future plan: recheck L eye 7 days time