C09986313 / invoice 10000

Appointment Reason: 1.3 CONSULT 3, Appointment Notes: O called back as now eye full of blood, unable to see at GSVH as ophthalmoscope is broken kmceye is weeping and O said eye has sunken in. Swelling around it. GTHistoryAttending DVM: ZY  Presenting Complaint: Acute onset OD changes this morning.    Hx: Owner noted the OD appeared sunken this morning, and later looked red/filled with blood. A mucoid / purulent discharge has also started this morning from that eye. The patient is squinting and keeping the eye closed intermittently. There is a history of running into a metal bar on the right side previously (not recent). Appetite has been intermittent since a GDV surgery approximately 5 months ago but he has otherwise been going well with no major health issues since GDV surgery    Diet/Appetite: Hit and miss appetite.  Current medications: None.  Prior Medical Issues:-   GDV surgery (~5 months ago) with delayed healing.PEx:Mentation: BAR, friendly, nervous  Weight: 40.5kg BCS: 4/9 MCS: 4/9  HR: 96 RR: Panting RE: normal MM: pink pigmented, moist CRT: 1.5s Temp: deferred  Hydration: euhydrated  Perfusion: well perfused    Cardiovascular: no murmurs or arrythmias, normal pulses  Respiratory: clear lung fields, no adventitious sounds  EENT: Eyes: See Ophthalmic Exam. Ears: no erythema/discharge. Oral: no overt disease.  Abdominal: soft and comfortable on palpation, no organomegaly  Integument: clean healthy coat, no dermatitis or skin lesions  MSK: ambulating well, no lameness, no spinal discomfort  Neuro: normal mentation, no central neuro signs  Urogenital: external genitalia clean  LNs: no peripheral lymphadenomegaly  Rectal: not performed    Pain score: 2/24 MCGPSDiagnostics:Ophthalmic Exam:  Neuro-Ophtho: Menace + OU, PLR (Dir/Cons) + OU  Anterior Segment:-   OD: Moderate intrastromal corneal hemorrhage. Focal hyphema around the medial canthus and medial hemisphere, spreading towards the iridocorneal angle. Pupil is constricted. Slight iridial injection noted peripherally. No significant scleral injection or aqueous flare. Lens appears in normal position without evidence luxation. no corneal lesions identified-   OS: Unremarkable.Posterior Segment:-   OD: Fundus is challenging to visualize. Tapetal reflex is intact. optic disc and retinal vasculature not visualised well-   OS: Unremarkable. - normla optic disc and retinal vasculature, normal tapetal fundusDiagnostic Tests: IOP: Pending. Fluor: Neg OU.    Other Diagnostics:-   Systemic blood pressure measurement: Pending.Assessment:Problem List:-   Acute OD hyphema & intrastromal corneal hemorrhage: Sudden onset bleeding within the anterior chamber and corneal stroma. Ddx: Traumatic contusion (reported history of running into bar), neoplasia (e.g., iridociliary tumor - uveal melanoma etc), secondary to chronic uveitis. altered vascular permeability / vascular fragilityUnderlying KCS to be ruled out pending STT / tearfilm breakup time (no prior suggestion for KCS in history)Treatments & VaccinationsProcedures: Admitted into hospital for diagnostics and observation.Plan:-   Perform IOP measurement (pending tonometer arrival).-   Perform systemic blood pressure measurement.-   Pending IOP results, plan to start topical corticosteroid therapy.-   If IOP is elevated, will call owner to discuss glaucoma therapy.-   Recheck: Re-evaluate in 12 hours.-   Discussed potential for specialist referral if condition progresses.  Update:IOP measures in hospital:OS - 10-12mmHg over several readings - abberant reading of 14-15mmHgOD - 8-9mmHg over several readingsMild to moderate evidence anterior acute uveitis unilaterally, no obvious evidence on contralateral eyeDiscussed with owner given acute onset anterior segment haemorrhage, recommendation to commence topical steroid therapy to help with inflammation, control further haemorrhage and allow time for resorption through iridocorneal angle. Discussed cannot rule out underlying causation at this stage, pending response would consider referral if worsening ocular signs.Discussed timeframe of improvements / static progression over next 7d.potential longer period for intrastromal corneal haemorrhageHyphaema should be resorbing/non progressive within next 7-10d    Vital Signs