C09992347 / invoice 10000

History:Presented for Right eye ulcer checkLast check up 4 days agoCurrent meds: Tricin OU TID and oral Onsior 10mg PO SID (Finished) and Gaba 50mg BID (Finished)O apply E-collar occasionally, also noted rubbing on eyesAssessment:BAR, EDDU, BCS 3/5Ocular exam:Right eye: Mild blepharospasm, Eyelids WNL, inflame conjunctiva, Superficial perilimbal hyperaemia, corneal clear with a ~0.2cm diameter defect at centre lateral corneaLeft eye: WNL2 drops Alcanin applied to OD, nil fb/grass seed behind third eyelid/conjunctiva sacs,Fluorescein test: A ~0.2cm Positive uptake at centre lateral cornea ODGentle debrided the defect with cotton tip todayPlan:Continuous on Tricin Right eye TID for another 5 daysDoxy 50mg Half tab (3.6mg/kg) PO SID for 6 daysRe-start Onsior 10mg PO SIDStrictly apply E-collar at homeRecheck eye in 3-5 days, sooner if concern.

Reason: recheck R eye corneal ulcerHistory:Dx with R eye upper lateral quadrant corneal ulcer. Tx with tricin and meloxicam for pain relief.Update from owner:Dog has been doing well at home.No issues with eye meds.No discharge from R eyeExamination:Oral: mm - pink, crt 1 secEyes:- L eye: NAD, no fluorodye uptake- R eye: very small 1mm superficial corneal ulcer present at right upper lateral quadrantTreatment:Continue with current tx with eye ointmentPlan:Recheck on Friday

1) Reason: Right eye corneal ulcer2) History: Appetite: normal Gastric: normal stool, no v/d present Resp: no coughing or sneezing present Skin: NAD Meds: NO Preventives: Vax up to date in March 2025Problem:Owner noted dog has been squinting his right eye for the last 3 days.Younger dog at home, rough playing with each other.3) Examination Behavior: good boy in clinicWeight: 6.4kg, B/S - 3/5 Oral: mm - pink, crt<1 sec Dental score: 1-2/4 Eyes:- L eye NAD- R eye corneal ulcer present on lower medial quadrant 3mm dia superficial ulcer- topical GA: no FB present, inflamed 3rd eyelid gland both eyesEars: NADLNs: normal Cardiovascular: no heart murmur oscillated, cardiac rhythm - normal Respiratory: lungs clear, breathing normalAbdomen: NADSkin: NADMusculoskeletal: - FLs: NAD- HLs: NAD- ACL, Patella: stableUrogenital: NAD Neurology: NAD Comments 4) Diagnosis: Right eye corneal ulcer5) DDX: trauma6) Treatment: Tricin into BOTH eye QIDOnsior 10mg SIDGabapentin 50mg BID7) Plan: Recheck on wednesday