C09976004 / invoice 10000

Reason: Y - Sore Eye - LJEHISTORY:Current meds:Prophylaxis:Pre-existing conditions:Access to toxins eg. Rodenticide:TRIAGE:HR:RR:Temp:Mm: Crt:Mentation:EXAMINATION:Body Condition Score: Pain Scale (0-4):Hydration status (%):Cardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: neurologically no significant findingsMusculoskeletal: ambulating normally, no palpable neck, spine, limb or joint painGastrointestinal:- Oral: normal, no mouth pain, dental score (1-4):  - Abdominal: no detectable pain on abdominal palpation, normal gut sounds- Rectal: no detectable abnormalities Urinary: NSFReproductive (incl ext genitalia): NSFIntegument/Ears: NSFLymph Nodes: NSFEyes: NSFPROBLEM LIST:DIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:DIAGNOSTICS:ASSESSMENT:TREATMENT:PLAN:CLIENT COMMUNICATION:A fluorescein stain was performed, the findings of this test were:- Left:- Right:A Schirmer Tear Test was performed to assess tear production.  Normal = >10mm in 60 secLeft eye:Right eye:This is consistent with:    Vital Signs