C09995243 / invoice 10000

Reason: IOP RECHECKAppointment Notes: Overdue remindersReason: History:- Recheck right eye.- On Dozalamide TID and oral meloxicam- O think eye seems a bit better. Eye smaller, less blue, more brown pigment visible.- O does not think P is bothered by the eye even before starting meds- Eating/drinking normally.- No V/D.Examination:- Mentation: BAR.- R eye slight proptosis, blue/corneal oedema, thick vessel on sclera/injection, mydiasis (not miosis?), absent PLR and menace response. IOP three separate reading taken: 69, 68, 48. No corneal ulcer noted- L eye no episcleral injection. PLR and menace intact. No corneal ulcer. IOP: 16, 15, 16.Assessment/differential diagnosis:- Right eye glaucoma likely with uveitis, non-responsive to medical management. The eye is blind and likely painful. Recommended sx intervention with right eye enucleationTreatment:- Continue Trusopt/dozalamide eye drops TID R eye and NSAIDPlan:- Recommend right eye enucleation.- Continue current medications (Unisom eye drops and oral anti-inflammatory) while awaiting surgery.- Book surgery for as soon as possible, potential availability next Monday.Client Communication:- Discussed lack of response to medical treatment and ongoing inflammation in the right eye. Explained the eye is blind and likely painful despite not showing overt signs of discomfort. Recommended enucleation of the right eye to improve quality of life. Client understands the left eye has vision and quality of life should not be significantly impacted. An estimate for the surgery will be prepared and emailed to the client. Advised to book the surgery as soon as possible. Discussed continuing all current medications until the surgery. Confirmed client's email address.    Vital Signs