C09972099 / invoice 10000

Reason: Initial - Lump On/next To AnusAppointment Notes: Hx req 16/02Medicine referral summaryReason:History:Perianal mass identified in April 2022. At this time 6mm in the 4 o clock position. Wedge biopsy: chronic pyogranulomatous and lymphoplasmacytic dermatitis with fibrosis. In the deeper section there was a possible sinus tract on histology. DDx bacterial, migrating FB, furunculosis. Treated with a 4 week course of amoxiclav.Initial resolution noted but relapsed in April 2025 - licking his bottom, blood noted. 6mm mass noted below the anus, with a scab, which when squeezed a mass emerged underneath. Separate to anal sacs. Amoxiclav dispensed. At follow up lesion resolved. November 2025 mass noted again, waxing and waning, this time described as on the left side of the anus external to where the anal sac would be, palpating as fluid filled. FNA RBC and purple material on microscopy. Treated with meloxicam and amoxiclav for 7 days. At a follow up still present, and able to be expressed with "cellular" material. At follow up was ulcerated. Surgical removal recommended. Progress with treatment Some improvement with amoxiclav and NSAIDs Signs noted - Visible mass- No dyschezia or tenesmus. No diarrhoea, formed and normal - Will lick the area - Will bleed- Some lethargy when bleeding- EDDU normal. No vomiting. - No scooting Current medications: - None Worming: UTD with worming not sure what product, spot on Diet: Dry food Other medical issues: - Polyradiculoneuritis in 2021 Physical examination:Demeanour - Bright and alertVital signs - MM pink, CRT<2s, HR  bpm, RR  bpm, T  CCardiovascular - Cardiac auscultation normal, pulses strong and synchronousRespiratory - Effort normal, bronchovesicular sounds audible all quadrantsAbdomen - No abnormalities on palpationHead / neck - No abnormalities identifiedMusculoskeletal - Normal gait, no pain identifiedIntegumentary - No abnormalities identifiedGenitourinary - No abnormalities identifiedLymph nodes - Peripheral lymphadenopathy not detectedBCS  /9. Body weight  kg.Procedures:Premed - Anaesthesia - Laboratory:Haematology -Biochemistry - Urinalysis - Imaging:Assessment:Treatment:Plan:Client communication:Vet communication:    Vital Signs