C09974496 / invoice 10000

Reason: Recheck Eye RS- Time: 2026-02-16 15:56:40- Patient: Elvis- Diagnosis (prior): Left corneal ulcerDiagnostic History- Medical History: Previously diagnosed with a superficial corneal ulcer in the left eye; initial ulcer estimated at ~1–2 mm diameter. No reported scratching at the eye. Some mild morning ocular discharge noted by owners.- Medication History: Completed a 7-day course of topical ophthalmic antibiotic ointment twice daily for the left eye. No cone currently used. Plan to continue ointment for another 7 days.Subjective- Reported concerns: Persistent eye redness, mild morning discharge from the left eye. Owners report no scratching or keeping the eye closed. Tolerated cone and ointment initially after some resistance.- Symptoms:  - Mild morning ocular discharge (left eye)  - Redness persists  - No blepharospasm reported  - No noted pruritus/scratchingObjective- Attitude: BAR- EENT: No erythema or debris AU. Eyes clear and bright OU except left cornea with superficial ulcer. No nasal discharge or sneezing.- Specific abnormal findings:  - Left corneal ulcer: superficial, irregular shape, approximately 5 mm diameter at longest axis, increased from prior 1–2 mm estimate.  - Fluorescein uptake consistent with a superficial spreading corneal ulcer.  - Performed in-clinic gentle debridement of ulcer edges using a cotton-tipped applicator moistened with topical local anesthetic to encourage epithelial healing.  - Temporary blurry vision expected in left eye for a few hours post–local anesthetic.Assessment- Assessment: Superficial corneal ulcer, left eye, with interval increase in size and irregular margins; likely secondary to initial scratch/trauma. Despite prior 7-day antibiotic ointment course, ulcer has spread superficially; debridement performed to promote healing. No signs of deep stromal involvement or melting keratitis on exam today.- Differential Diagnosis:  - Persistent/refractory superficial corneal ulcer (indolent ulcer)  - Traumatic corneal abrasion with delayed epithelial adhesion  - Secondary bacterial keratitis (prevented/controlled with antibiotic ointment; no purulent discharge noted)  - Foreign body irritation (less likely; not observed)  - Entropion/trichiasis causing ongoing irritation (no eyelid abnormalities noted on today’s exam)  - Dry eye (keratoconjunctivitis sicca) — less likely given lubrication plan, but consider if delayed healing persistsPlan- Diagnostic observations/tests:  - Fluorescein staining positive in left eye; superficial pattern with irregular edges.  - Weight confirmed at 4.9 lbs on small-dog scale.- Prescription:  - Continue ophthalmic antibiotic ointment to the left eye twice daily for 7 more days.  - Topical local anesthetic was applied in-clinic for debridement; no take-home anesthetic prescribed.- Next Steps/Investigations:  - Recheck appointment in 7 days (on or after 2026-02-23) to reassess ulcer healing with repeat fluorescein staining.  - If ulcer persists or worsens: consider switching/adding a different topical antibiotic, adding a cycloplegic (e.g., atropine) for comfort if uveitis signs develop, Schirmer tear test to evaluate tear production, eyelid evaluation for entropion/trichiasis, and potential referral for diamond burr debridement or grid keratotomy if an indolent ulcer is suspected.- Further Treatment Plan:  - Maintain twice-daily ointment application; ensure the tip does not touch the eye.  - Use an E-collar if any rubbing or scratching occurs.  - Monitor for increased redness, pain (squinting), mucopurulent discharge, or vision changes; if noted, contact clinic sooner.- Owner communication and other notes:  - Discussed that antibiotic ointment primarily prevents secondary infection and provides lubrication; ulcers typically heal with time unless indolent.  - Explained debridement purpose: to remove non-adherent epithelium and encourage proper healing.  - Advised possible transient blurry vision in the left eye for a few hours due to local anesthetic used today; right eye unaffected.  - Medication supply: If ointment supply runs low, clinic can dispense another tube.  - Declined services: None noted.    Vital Signs    Weight: 4.9;