C10031794 / invoice 10000

SubjectivePresenting Concerns:  Archie presented for evaluation of a OS injury that occurred last night following an altercation with another dog. The owner reports that the eye was weeping a brownish discharge and appeared red. The patient was also observed squinting.    Current Medications:-   The owner administered Gabapentin prior to the visit.  Lifestyle Risk Factors:-   Lives in a household with 2 other dogs.Objective: (target examination)Mentation: Bright, alert, and responsive  Wt: 32  T: Unable to obtain, reading as too low. Patient was noted to be cold to the touch.    Emotional Assessment: The patient was very excited and wiggly during the examination. The pre-visit Gabapentin did not appear to be effective.    Eyes: The conjunctiva is hyperemic bilaterally, but there are no obvious puncture wounds or significant inflammation. The third eyelid and anterior chamber appear normal. No discharge was noted.    Point of Care Diagnostics:-   Fluorescein stain: Negative for corneal ulceration in OU.AssessmentTraumatic conjunctivitis, OS - Secondary to an altercation with another dog. No corneal ulceration was detected on fluorescein staining.  PlanMedications/Treatments:-   Dispensed an ophthalmic ointment to be applied to the OS for the next few days to manage the conjunctivitis. Chlorasone eye ointment.  Additional Discussion:-   The owner was advised to return for a recheck examination if the eye condition worsens or fails to improve.    Vital Signs