C10015848 / invoice 20000

Appointment Notes: 7.30am R eye mass removal GAP Insurance & last consult **remember to increase estimate if margins are required**Objective: HR/PR: 144RR: pantingTemp: 39.2CRT: pink and moistStatus: ASA 2Laboratory:  PAS DeclinedTreatment: Premed methadone 0.33ml IV @ 10:27amInduction alfaxalone 2.3ml IV @ 10:40amIntubated and maintained cuffed ET tube size 6.5, iso 2% in O2 1L/minSurgery started @ 10:57amTechnique:> Eyelid clamp placed to protect globe.> Wedge incision made around mass + removed.> 4/0 novosyn figure 8 suture placed to close. Good apposition.Surgery finished @ 11:06amAnaesthesia finished @ 11:06amRecovery smoothPain relief meloxicam 0.43ml SC >> TGH meloxicam 1mg SID PO for 4 days starting tomorrowPlan: FUC tomorrow> Wound check in 10 days> E-collar on until then> Continue chlorasone in the mean time, recheck STT at POC. If still low consider optimmune once eyelid healed.    Vital Signs    

Appointment Notes: Final recheck  ------- Sms reply: YesSubjective: Here to recheck  L eye post enucleation + R eye conjuncitivits> No concerns RE enucleation site> OR that R eye improved on chlorasone, but the day after she stopped it (sunday), the eye became gunky and red again. OR there is also a new pass on the R eye upper eyelid which is growing quicklOtherwise well in herselfDUDE, no V+ or D+BAR in consultObjective: HR/PR/CV: 100, normokinetic, G2 murmur PMI left heart baseMM/CRT/Hydration: pink and moist, 2 seconds, hydratedRESP/RR: lung sounds clearTemp: n/cGIT/UG:  comfortable on palpationSkin/Ears: L eye enucleation site well healed, no swelling, erythema pain or discharge, sutures in place.M/S:  Ambulating well in consultEyes:R eye:> Marked conjuncitval + scleral hyperaemia> Mild thick yellow mucoid discharge medial canthus> 1cm deep red/hyperaemic mass on the lateral middle side of the upper eyelid, contacting eye. Lump is weeping blood from its base.> STT 8mm> IOP 13mmHg> Negative fluoresceinDental: n/cLymph Nodes: NADBCS: 5/9Assessment: > L eye enucleation site well healed> Rapidly growing + bleeding mass inner L upper eyelid contacting cornea - concern for ulceration of cornea, cannot rule out neoplasia. > Consistently low STT, scleral + conjuncitval hyperaemia + discharge which improves with chlorasone - suspicion for KCS.Treatment: > Continue chlorasone R eye BID until after eyelid mass removal Sx.Plan: Booked in for R eyelid mass removal. Once healed, transition from chlorasone on to optimmune and monitor 2 weeks later.    Vital Signs