C09993207 / invoice 10000

Reason: Eye ProblemAppointment Notes: aware of fee. aprilHistory:Sustained minor trauma to the left eye in 2024, thought to be due to vision impairment from cataracts and was subsequently evaluated by ECA. Cataract surgery was performed, however the procedure was unsuccessful in the left eye due to glaucoma, and the eye is now completely blind. Over the past few days, the patient has been squinting in both eyes. An infection of the right eye was detected yesterday by the ECA. Following administration of dorzolamide/timolol drops today, the patient became markedly irritated and rubbed at the eyes, after which the left eye began weeping and bleeding.Current medication: Ocuflox q1 OD since yesterday, chlorsig q1 OD since yesterday, normal eye drops include xalatan OS q12hrs, predforte q24hrs OU (avoided the last 2 days), dorzolatim (cosdor) q12hrs OUExamine:Difficult to examine due to anxious temperamentBright, alert and responsive. Mucous membranes pink with no oral lesions, moist and CRT<2 seconds. Heart rate 120 beats per minute with no systolic heart murmur and no arrhythmias. Femoral pulses were synchronous, strong and symmetrical. Normal respiratory effort and unremarkable lung sounds. Abdomen felt smooth, allowed deep palpation and no organomegaly noted on palpation. Peripheral lymph nodes were not enlarged or painful. Rectal temperature was not taken. Adequate hydration. BCS 5/9. BWT 13.5 kg. On examination of the eyes, no evidence of blepharospasm, mild epiphora and conjunctival hyperaemia on the left eye. The left cornea appears mildy oedematous, but does not appear deflated.Procedure:Fluorescein stain revealed a central circular lesion of uptake on the left cornea, with no uptake in the centre. The right eye had a small linear region of uptake on the ventral aspect of the cornea. Assessment:Bert presents following an acute trauma to left eye. The left eye is known to be blind secondary to glaucoma following cataract surgery performed in 2024. Ocular exam and fluorescein staining consistent with a descemetocoele vs full perforation. The left cornea also appears mildly oedematous with mild epiphora and conjunctival hyperaemia. The right eye demonstrated a small linear region of fluorescein uptake on the ventral cornea, consistent with a known corneal ulcer. Pain levels hard to assess due to anxiety. Overall, the left eye lesion requires urgent assessment by the ECA.Treatment: Meloxicam 0.1mg/kg SCBuprenorphine 0.02mg/kg SCOcuflox and chlorsig OU q1-2hrsClient Discussions:Discussed concerns over descemetocoele vs full perforation. Advised to present to ECA as soon as it opens tomorrow. Plan:Pain relief and topical antimicrobials + cage rest and E-collar. To present to ECA tomorrow morning.    Vital Signs    Weight: 13.5;       MMColour: PInk;       HeartRate: 120;       CRT: <2;       

Reason: Eye ProblemAppointment Notes: aware of fee. april-----------------------------TRIAGE NURSE:History:Client Discussions:    Vital Signs    Weight: .01;