C10018618 / invoice 10000

DATE/TIME of CONSULTATION: 19:16hrs, Wed 11/03/26
CLINICIAN: Sarah Triglia
PRESENTING COMPLAINT: Eye ulcer
HISTORY: This morning owner noted blepharospasm left eye. Still BAR and eating well. 
No medications currently

CLINICAL FINDINGS: BAR, lovely girl
MM pink<2. Temp not taken
Heart and lungs normal on auscultation, HR 120
Abdomen normal and comfortable
Mild blepharospasm LEFT eye - scleral hyperemia + corneal oedema. Perhaps very slight fluoro uptake centrally? Pupil is slightly more miotic that the right eye, however unable to perform tonometry (much too wriggly!) to check this

DIAGNOSIS: Small ulcer left eye +/- uveitis

TREATMENT:
* Chlorsig left eye TID
* Meloxicam PO SID
* Doxycycline PO BID
* Revisit at RV in 3-5 days

DATE/TIME of CONSULTATION: 21:14hrs, Sun 21/09/25
CLINICIAN: Dr Peter Ballis

PRESENTING COMPLAINT: Swollen L eye.

HISTORY:
O noticed discharge from L eye earlier today.
Nugget has been rubbing at the eye.
This evening eye looking more red and swollen.

CLINICAL FINDINGS:
Serous dc L eye.
B'spasm.
Can see corneal opacity.
Alcaine instilled into both eyes.
Fluorescein stain applied.
Large, oval shaped ulcer L cornea.
Ulceration app 8mm long by 4 mm wide.
R eye corneal lipidosis but no fluorescein uptake.



PROBLEM LIST:
Corneal ulceration L eye.


OPTIONS PROVIDED:
Home with meloxicam SID and doxycycline 50mg BID.
RV reg vet 4-5 days.
Discussed ulcer won't necessarily have healed by that visit but will hopefully be smaller.
Discussed grid keratotomy +/-  temp tarsorrhaphy INI.