C10031152 / invoice 10000

Reason: Conjunctivities Appointment Notes: stuggles alot with eye drops alot- wasnt consistant last time milO called and spoke to PC, just wanting script no visit, PC explained visit rec in case of changes to eye. PCHistory: - Conjunctivitis, previously diagnosed but inadequately treated - Difficulty administering topical eye medication due to facial sensitivity - Previous attempts at restraint unsuccessfulPhysical examination:General: Bright, alert, and responsive (BAR). Ambulatory with a normal gait.BCS: 5/9. Well-hydrated.Vitals: Temp normal. HR and RR within normal limits.Head/Neck: Symmetrical, no masses.Eyes: Clear, no discharge. Pupils equal and responsive to light.Ears: Canals clean and dry, no erythema or odour.Oral: MM pink and moist, CRT <2 seconds. Minimal dental calculus, no significant gingivitis.Integument: Healthy coat, no alopecia, scaling, or parasites noted.Lymph Nodes: Peripheral lymph nodes non-palpable/within normal limits.Cardiovascular: Normal sinus rhythm, no murmurs or arrhythmias auscultated. Pulses strong and synchronous.Respiratory: Lungs clear on auscultation bilaterally, no abnormal sounds.Abdomen: Soft, non-painful on palpation. No organomegaly or masses detected.Musculoskeletal: Normal range of motion in all limbs, no pain on flexion or extension.Neurological: Appropriate mentation, conscious proprioception normal. No neurological deficits noted.Assessment: - Problem list: 1. Conjunctivitis requiring ongoing treatment 2. Behavioural issues with facial handling and medication administrationPlan: - Eye drops prescribed (script provided for chemist collection, store in fridge once opened) - Alternative application method discussed: apply small amount of ointment to finger and wipe around eye area - Sedation protocol for anxious behaviour: gabapentin 2 tablets plus trazodone 1 tablet given 2 hours before stressful events - Optional: additional dose night before if severe anxiety - Trial sedation at home first to assess response - Gradual desensitisation to eye handling recommendedCommunications: - Discussed concerns about forceful restraint creating long-term handling issues - Explained sedation options for clinic visits and grooming - Advised medication effects last up to 12 hours - Counselled on rare possibility of paradoxical hyperexcitability with sedation - Recommended starting with lower sedation dose and adjusting as needed    Vital Signs    Weight: 13.1;