C09973479 / invoice 10000

Reason: Irritated EyeAppointment Notes: PHYSICAL 28.2.26 BGBAR HR = 160RR = 24MM = pink CRT = 1-2pulses = strong and synchronous temp = 37.5Record Entered by: Ilse Huinink (DVM4 student)Record Checked by: Dr. Alexander PanakosHistory:Lucy, a 2 year old female spayed Burmese, was presented to the ECC department due to an inflamed right eye. The owner first noticed yesterday evening that there was an increased epiphora of the right eye. This morning, there was also yellow-green exudate from the same eye, with redness of the skin, conjunctivitis and increased episcleral vascularisation. Lucy squints when looking into bright lights, but no signs of blindness or pawing at the eye. The owner put a warm wet compress on it, but no change.There is a new kitten in the house since 2 weeks. The cats play a lot, and the kitten might have scratched Lucy. She has a history of herpes, with an inflammation of the eye as a kitten after the death of another pet. EDDU no abnormalities. No coughing/sneezing. No diarrhea. Tonight 1x vomiting after eating fast. Indoor only, vaccinations and parasite prevention UTD.Physical Examination Temperature: 			37.5 CBody condition score: 	            5/9Body weight: 			3.45 kgDemeanour: 			BAREyes/Ears/Nose/Throat: 	Increased epiphora right eye with green-yellow exudate, 				conjunctivitis + increased episcleral injection + red skin around 				right eye. Left eye normal. Ears clean without scent, no reaction on palpation of 				throat and no palpable abnormalitiesPeripheral lymph nodes: 	Mandibular, retropharyngeal, prescapular, axial, inguinal and 				popliteal lymph nodes normal size and consistency, no painIntegument: 			No lesions or parasites. Healthy coat and skin.Cardiovascular: 		160 /min, MM pink and moist, CRT <2sec, no heart murmurs 				or arrhythmias, femoral pulses strong and synchronous.Respiratory: 			24 /min, no wheezing or crackles, normal bronchovesicular 				sounds bilaterallyAbdominal: 			No palpable abnormalities on superficial or deep palpation of 				the abdomen. Comfortable on palpation. Bladder small and 				comfortable, kidney palpation unremarkable. Musculoskeletal: 		No lameness or ataxia appreciated. Full MSK exam not 				performed.Neurological: 			Normal, appropriate mentation. Full neuro exam not 				performed.Rectal: 			            Perineal area clean, no inflammation. Rectal exam not 				performed.Urogenital: 			No discharges from vulva. Desexed animal. Diagnostics/laboratoryFluorescein positive right bottom quadrant eye with superficial ulcer (photos attached to discharge letter)Assessment:Superficial ulcer right eye (conjunctivitis, increased episcleral vascularisation, red skin, squinting, yellow-green exudate)The ulcer is most likely caused by trauma, as it occurred unilaterally. The yellow-green exudate indicates the likely involvement of bacteria in the wound.Plan:Chloramphenicol 1% eye cream every 6-8 hours for 7 days. Re-check after 5-7 days with regvet for a re-evaluation fo eye. Possibly extend treatment course if the ulcer is not fully healed then. An e-collar was discussed, but deemed not necessary at this time by the owner.    Vital Signs    Weight: 3.45;