C10001638 / invoice 10000

poss eye ulcer

GapOnly
Pet Primary Diagnosis/Suspected Diagnosis:()
Suspected Cause:()
Any other conditions being treated, if any:()
Known health concerns:()
Date of first clinical signs, if known:()


HISTORY
Presenting for: Franklin, a pug, presented for examination of a left eye problem with blepharospasm and allergies. Patient is boarding from 5th to 14th.
Current Meds: Pet insurance with Pet Insurance Australia
Other: Patient has been well otherwise, eating, drinking, toileting normally. No current medications.

EXAM
Mentation: BAR
Wt: 9.9 kg
T: 37°C
Behavioural: Very food motivated, readily accepts treats during examination
Eyes: Left eye - blepharospasm, cloudy appearance, tear overflow, conjunctival erythema. Superficial corneal ulcer approximately 1mm diameter confirmed with fluorescein stain under UV light. Right eye - normal
Diagnostics: Fluorescein stain - positive for small (1mm) superficial corneal ulcer left eye

ASSESSMENT
Superficial corneal ulcer, left eye - Small (1mm) superficial ulcer in a brachycephalic breed with prominent eyes making him vulnerable to ocular trauma

PLAN
New Meds/Tx:
- Eye drops QID for corneal ulcer
- Metacam SID for anti-inflammatory effect
- E-collar (15cm) to prevent rubbing/scratching of affected eye
Additional Discussion:
- Patient requires air-conditioned environment due to brachycephalic breed wearing E-collar
- Recheck examination required in one week (when owners return 14th) to ensure healing
- If ulcer not healed within one week, further investigation required
- Monitor for worsening signs including purulent discharge or inability to open eye
Client Comms:
- Contacted owner (Michael Cunningham) to advise of corneal ulcer diagnosis
- Insurance claim to be processed via gap payment system with Pet Insurance Australia
- Updated contact details on file
- Advised recheck examination required upon return from holiday