C09999749 / invoice 10000

Reason: Discharge / EyeAppointment Notes: Paws App Details:Booking Type: Consultation - Skin / Ears / EyesBooking Vet: - Any -Booking Notes: Eye dischargeHistory::Signalment - 7-year-old male neutered Cavoodle, 7.75 kg  Presenting complaint - Right ocular discharge and corneal opacity for approximately 6 months.  Current health status - Otherwise well.Examination::BAR  HR - 110  RR - Pant  Temp DNP  CRT - < 2 sec  MM - Pink, moist  LN's - All peripheral LN's palpate normally  Eyes - Right eye: Mucoid discharge, corneal opacity, and a sizable corneal ulcer (positive fluorescein stain uptake). Schirmer tear test 3 mm/min. Left eye: Within normal limits. Schirmer tear test >15 mm/min.  Ears - Clear vertical canals. Normal amounts of waxy discharge. No inflammation or stenosis visualised  Thoracic Auscultation - No murmurs or arrhythmias auscultated. Normal bronchovesicular sounds bilaterally  Abdominal palpation - No pain response on palpation. No abnormalities palpated.  Urogenital - WNL  MSK - Ambulating normally for signalment.  Neuro - CN's function normal. No ataxia  Integ - WNLAssessment::Problem 1 - Right Keratoconjunctivitis Sicca (KCS)  Notes/Comments - Likely immune-mediated.    Problem 2 -  Right corneal ulcer  Notes/Comments - Secondary to KCS.Treatment::Fremixin eye drops: Apply to the right eye 3 times daily.  Ocula eye lubricant: Apply to the right eye 4 times daily.  Compounded Tacrolimus eye drops to be ordered for long-term management.Plan::Recheck consultation booked for 1 week.  A cost estimate for Tacrolimus will be sent to the owner's daughter.  Advised to seek emergency care if condition deteriorates.    Vital Signs    Weight: 7.75;