C10030905 / invoice 10000

Reason: Derm Injection Check Eye FYGAP ONLY HISTORYFirst clinical signs - 1 week agoSummary - corneal ulcer R eyeDiagnosis - corneal ulcer R eye still persistingTreatment - continue meds and add hyloforte, referral to eye specialist asapHISTORY:Examine:PHYSICAL EXAMINATION: Mentation: alert and responsiveEYES: NAD - clear, no noted discharge #EARS: NAD - clear, no discharge, odour, erythema#NOSE: NAD - clear, no discharge, symmetrical, no lesions #ORAL: NAD - normal pink and moist mm, normal CRT, healthy teeth & gums#CARDIOVASCULAR - NAD - no murmur or arrhythmia auscultated, pulse pressures normal and synchronous#RESPIRATORY: NAD - thoracic auscultation clear sounds bilaterally, respiratory effort normal#ABDOMINAL: NAD - soft pliable, no detectable pain or palpable abnormalities#NEURO: NAD - neurologically no significant findings, no cranial nerve or proprioceptive deficits/gait#MUSCULOSKELETAL: NAD - ambulating with normal gait & posture, no pain on palpation of joints, appropriate ROM#RECTAL: not performed#REPRODUCTIVE: externally normal #INTEGUMENT: NAD - clear coat and skin #LYMPH NODES: NAD - peripheral nodes palpate normal #Assessment:Treatmentinjection given - 100units silver vialWhen is the next dose due?: no more - due for visit with specialistPlan:    Vital Signs    Weight: 5.5;