C09970619 / invoice 10000

Reason: Lump On Jaw Dental Abcess?? Appointment Notes: BG0413645172 ?Consult Time: 1800HISTORY:Presented for assessment of an acute onset left-sided facial droop, noted by the owner approximately 1.5 hours prior to consultation. The owner observed food falling from the left side of Gertie's mouth while she was eating a dental stick. The owner's husband had noted something unusual the previous day while Gertie was eating grass. On initial examination by the owner, a lump was palpated on the left side of the face. There is no known history of trauma. A piece of cat grass was manually removed from the left buccal mucosa during the consultation. Gertie is 9 years of age.Current meds: noneVaccination: Not mentionedParasite Prevention: Not mentionedPre-existing conditions: noneAccess to toxins eg. Rodenticide: noneEXAMINATION:Body Condition Score: 5/9Pain Scale (0-4): 0/4Hydration status (%): hydration clinically adequateCardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: neurologically no significant findingsMusculoskeletal: ambulating normally, no palpable neck, spine, limb or joint painGastrointestinal:Oral: A piece of cat grass was removed from the left buccal mucosa. The area is swollen, bruised, and thickened with sores along the gum and mucosal area, consistent with a pressure injury from the foreign body.Abdominal: no detectable pain on abdominal palpationRectal: not performedUrinary: NSFReproductive: NSFIntegument/Ears: NSFLymph Nodes: NSFEyes: NSFDemeanour/Behaviour: not discussedPROBLEM LIST:1. Left buccal foreign body (cat grass)2. Left buccal mucosal swelling, inflammation, and ulceration3. Left-sided facial droopDIFFERENTIAL DIAGNOSIS/DIAGNOSIS:Left buccal foreign body with secondary inflammation and facial nerve compression/neuropraxia.DIAGNOSTICS:Bloods were taken for in-house testing:Please find attached to the patient record.> BiochemistrySignificant findings: A kidney profile was performed to assess renal function prior to starting anti-inflammatory medication. Results were within normal limits.ASSESSMENT:Gertie presented with an acute left facial droop. Examination revealed a piece of cat grass embedded in the left buccal mucosa, which was manually removed. The surrounding tissue is significantly inflamed, bruised, and ulcerated, likely causing compression on the facial nerve, resulting in the observed facial paralysis. A pre-medication kidney screen was performed and was unremarkable.TREATMENT:Manual removal of buccal foreign body (cat grass).Antibiotics: Xanrelia tablets prescribed to be crushed with food.A pre-medication blood test (kidney profile) was performed to ensure safety before potential anti-inflammatory use.PLAN:Re-check with regular veterinarian recommended within the next few days.Diet modification: Soft food only for now. Avoid hard foods, dental sticks, and bones to prevent further trauma to the oral cavity.If bones are given in the future, large marrow bones are recommended to prevent breakage and potential for slap fractures.Home into owner's care.CLIENT COMMUNICATION:Discussed the findings of a grass foreign body causing a pressure injury and likely temporary nerve damage, leading to the facial droop. Advised on the treatment plan including a course of antibiotics. The cost of a focused kidney blood profile (approx. $200) was discussed and approved by the owner to ensure the safety of potential future anti-inflammatory medications. Advised to feed only soft food and to re-check with their regular vet. Discussed appropriate bone choices for the future to minimise dental injury risk.    Vital Signs    Weight: 32.2;       HeartRate: 128;       RespirationRate: pant;       PainScore: 1/4;       CRT: 2;       MMColour: p/m ;       

Reason: Recheck Ear And FNA Lump - Leave LongAppointment Notes: LGHistory: Has been on auracol 1mL both ears bidFinished a few days agoNoticed lump on ear has regressedNo ear worry BAR and eating well. Still on the rice and chicken Examination: Both ears very clean, minimal brown discharge in ears.  No erythema, both TMs intact R ear - small hairless mass 0.5cm diam - much smaller than prev. Laboratory: Cytology:   debris only in both earsAssessment: OE resolvedSuspect histiocytoma on ear - regressing now.Treatment: Plan:Owner to r/v if mass increases in size or does not go away. Expect to be fully regressed after 1 mth.--- 10/09/2018 08:46:43 AM WK4:Examinations - Resolved - follow up  done. kw    Vital Signs    Weight: 26.6;       

Reason: Recheck After AEC - Needs Fentanyl Patch RemovedAppointment Notes: kwHistory: Hospitalised with AEC over weekend for suspect pancreatitis. (no U/S done) improved on supportive care. Home with fentanyl patch, protexin, esomeprazole. BAR and eating well at home. No vomiting or diarrhea observed Have noticed ears very redExamination: Laboratory: Cytology: yeast++  both ears. Assessment: Treatment: Cleaned with otoflushAuracol into both ears - demonstrated for owner Plan:Recheck in 5-7 days. Owner had a lot of questions re. AEC diagnosis, treatments, etc and lump on ear.Advised we can discuss rest next visit, and FNA the mass on ear. --- 31/08/2018 07:52:17 AM AJ6:Examinations - Resolved - Follow up SMS Sent. JNA    Vital Signs