MIKO – A1125722

MIKO – A1125722

**CORNEAL ULCER – NEEDS FOLLOW-UP VET CARE**

MALE, WHITE / GRAY, SHIH TZU MIX, 4 yrs
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition UNSPECIFIE Intake Date 09/16/2017, From NY 11412, DueOut Date 09/19/2017

Medical Behavior Evaluation BLUE
Medical Summary  Estimated age: 3-6 years based on dentition and overall appearance Microchip noted on Intake? Scanned neg on intake History : Stray, no hx available Subjective: Calm, alert Observed Behavior – Allows most handling. Moves face away from close exam but doesn’t try to bite. Objective BAR-H, MMs pink and moist, BCS 5/9 EENT: OD mild lenticular sclerosis and episcleral injection – normal fundic exam. OS large (2-4 mm) ulceration in the center of the cornea – the center of the defect is filled with clear, jelly-like tissue. Surrounding cornea has severe corneal opacity and neovascularization. Large amount of fur with a large amount of ocular debris forming firm spikes around the eye, primarily at the medial canthus – in both eyes but more severe OS. Ears clean, no nasal discharge noted. Oral Exam: Mild tartar PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: Male intact, testicles S/S MSI: Saliva staining or debris in front leg fur. Ambulatory x 4, skin free of parasites, no masses noted CNS: mentation appropriate – no signs of neurologic abnormalities Rectal: Normal externally Fluorescein stain of left eye: there is a ring of uptake around the defect in the left eye, but the center of the defect is not filled in with stain. Cleaned much of the debris at the medial canthus OS and trimmed some of the fur – pt became agitated so this was not completed Assessment: 1. Severe corneal ulcer – possibly descemetocele vs. perforated ulcer with a slow leak 2. Mild tartar Plan 1. Ofloxacin eye drops (NOT ointment – the ointment vehicle can cause further ulceration) 3-6 times daily x5 days 2. Rimadyl 25 mg PO SID x10 days 3. Atropine drops ideal – not in stock at this time 4. Serum drops 3-6 times daily x5 days 5. E-collar always 6. Recommend ophtho consult ASAP – pt may need conjunctival flap to save the eye Prognosis: Fair SURGERY: Okay for surgery 1088
Weight 14.1

 

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