C09970568 / invoice 10000

Reason: 3rd Eyelid ExposedConsultation Time: 1000History:Current:Presenting for assessment of left eye.Owner noted watery discharge from left eye yesterday evening (09/01/2026).This morning, third eyelid was prolapsed, covering approximately half of the globe. It has since retracted but remains partially prominent.Mild gunky discharge and redness of the conjunctiva noted.Potential inciting causes considered by owner: sand from beach visit on Thursday (08/01/2026), foreign body from crate, or wind exposure.No other clinical signs reported. Eating, drinking and behaviour are normal.Past Medical History:Concurrent or prior pertinent disease: Atopy, managed with Cytopoint injections (currently receiving two injections per month). History of intermittent knee issues, likely cruciate-related, managed with crate rest as needed.Family or breed history relevant to presenting issue: Owner aware of breed predisposition to knee problems and Intervertebral Disc Disease (IVDD).Exposure history to toxins, infections, or risks: Visited the beach on 08/01/2026.Current Medications: Cytopoint injections as needed for atopy.Physical Exam:Demeanour: Bright, alert, and responsive. Cooperative for examination.Circulation: Heart rate 100 bpm, no murmur, synchronous pulses. Mucous membranes pink and moist.Respiration: Normal thoracic auscultation, no abnormal respiratory effort.Abdominal palpation: Non-painful, no abnormalities detected.Skin: Coat in good condition. No significant findings.Eyes: Left eye: Mild to moderate conjunctival erythema. Third eyelid partially prolapsed. Serous discharge present.Neurologic Exam Findings: No deficits noted.Rectal temperature: 38.4Assessment: Left corneal ulcer.Plan:Diagnostics:Fluorescein staining performed on left eye.A 2 mm diameter, circular ulcer was identified on the lateral aspect of the cornea, just lateral to the midline.The ulcer appeared uncomplicated and did not expand with debridement.A thorough search of the conjunctival fornices and behind the third eyelid after application of topical anaesthetic revealed no foreign body.Therapeutic:Tricin ointment prescribed for the left eye.1. Left Corneal UlcerAssessment or likely diagnosis for issue 1: Uncomplicated superficial corneal ulcer.Investigations planned for issue 1: Fluorescein staining and examination under LA completed.Treatment planned for issue 1: Tricin ointment to be applied to the left eye three times daily for five days.Client Instructions:Apply Tricin ointment to the left eye TID for 5 days.Re-check with regular vet in 2-3 days for follow-up.If clinical signs resolve completely within 2-3 days and remain resolved, can complete the 5-day course and then cease treatment without a re-check.Seek immediate veterinary attention if there is any worsening of signs, including increased squinting, pain, redness, development of purulent discharge, or if the third eyelid becomes more prominent or with any other concerns.```Subjective: Objective: Temp  MM  CRT  HR  FP RRBCS: /9  Wt:  kgCV: RESP: GIT: U/G: Neuro: M/S: Integ: Ophth: LNs: INTERNAL  LABORATORYPCV/TS:(Dog: PCV 37-55%, TS 55-75 g/L)(Cat: PCV 30-45%, TS 62-81 g/L)LACTATE:   mmol/L		Blood Gas(sample type: arterial/venous)Abnormal parameters:Interpretation:IMAGINGAFAST:TFAST/Vet Blue:Radiography:Problem List:Assessment: Options Offered to Client:Treatment:Plan:Eye problems have the potential to become significantly worse in a short space of time. For this reason, your pet’s eye needs to be checked regularly for any progression of signs, or inflammation of the interior of the eye. Please return to the AEC or your regular vet immediately if you notice any change in the appearance of the eye. Please make an appointment with your regular veterinarian to have the eye re-examined within 24-48 hours. If you have any concerns about your pet’s progress before then, please contact your regular veterinarian or the AEC as soon as possible.Please give the medications as directed.    Vital Signs    Weight: 19.6;