C09996409 / invoice 10000

24/02/2026 Reason:
R eye blinking
History: 
Generally is well.
Clinical based salient history: 
EDUF, no Vt or D 
No tenesmus
No PD or PU
Parasite prophylaxis utd 
current medications: none 

Examine:
Mentation:BAR
Body condition score: 5/9
Vitals/triage:
MM:pink moist,CRT: <2sec
HR:120 RR: ~40 Panting
LN: WINL
Temperature: NE - 
Ocular: 
R eye STT >20 after 30 sec L eye 18mm
FC R eye central uperfical uptake - map of Africa shaped ( 40% cover
MIld conjunctival redness sclera WINL

Oral/Dental: NSF dental~ stage:0/4
Ears: no discharge or erythema 
Nose: externally normal , no discharges
Cardiovascular:no murmur or arrhythmia, pulses normal 
Respiratory: Mild strtor - WINL for breeds 
Gastrointestinal: mild splinting during exam but comfortable on abdo palp, no abnormal mass palpable 
Integumentary: NSF
Musculoskeletal:no gait abnormalities.
Neurological:No MS deficits in any of limbs, normal posture. Full neuro exam not performed
Urogenital: no abnormal discharges, externally normal.

Problem List:
R eye central irregular corneal ulcer- superficial but +ve FC uptake
Assessment/Treatment plan:
- Continue optimune as is
- Outflux dispensed
Diagnostics discussed with O and treatment plan agreed to by owner:
- corneal ulcer
Treatment given/dispensed:
Ocuflox
Next visit: Pending results, to dispense NSAID 
NOTE:
O has pre paid for 2 tubes of Optimune for us to order and keep until needed