C10006216 / invoice 10000

Eye

Clinical Exam

History:(P will rub face in sandy areas
Noticed last night eye was watery and looking swollen
Breathing noise has worsenedrecently - weather related (hot and humid) or stricture/other
Was dispensed Ondansetron at 4mg and needed 8mgs
When seen by locum vet here was recommended to go to Murdoch for a referal for further assessment of his upper airways - O hasn't hear from Murdoch - needs followup)
EDUF:well, No V+, no D+, no coughing)
Current medication:()
Past Hx/Diagnosis: (Had emergency BOAS surgery at WAVEs, then seen at another clinic for treatment of a stricture of airway (Rivervale?) Was told by Steve Metcalf not to sedate him)
Prophylaxis:(ND)


Physical examination:
Mentation (BAR)
Eyes (Right eye NAD, no discharge apparent
Left eye mod epiphora, fluoro stain uptake below midpoint approx 4mm x 2mm in a elongated bean shape
Flushed eye with saline)
Ears (NAD, clean and free of odour)
Nose (NAD, no discharge apparent)
Mouth (tartar on upper carnassials, tartar and PD disease 103, 104, 203, 204)
Skin tent (normal)
Integument (healthy)
Peripheral Lymph Nodes (NAD)
Heart ausculatation (no murmurs nor arrythmias heard)
Chest (No abnormal bronchovesicular sounds auscultated, significant stridor), RR (panting), 
Resp efforts (WNL)
Abdomen (NAD, no pain palpable)
Genitourinary (NAD)
Musculoskeletal (NAD)

Diagnostic tests performed: 
- (PE)

Assessment/Differential diagnosis:
1.(Left eye ulcer)
2.(Worsening of BAOS disease symptoms)
3.()

Laboratory:(nil)

Recommendations: (1) Chloramphenical ointment tid, r/c staining in 3-4days
2) Owner requested steroids for emergency use of upper airway crisis)

Treatment: (Chloramphenicol
Pred 5mg)

Plan:()