C09974506 / invoice 10000

Appointment Reason: Abscess, Appointment Notes: on upper jaw - possible tooth root abscess??HISTORYPresenting for: Bear presented for evaluation of a skin lesion discovered this morning around 10-11am, appearing as a raised, round, inflamed area that the dog has been scratching at irritably. Does have one other dog at home so possibly started as small wound 2ndary to playing. Diet:- Dry biscuits- Had eating difficulties 1-2 months ago but appetite has improved over the last 2 weeks- No recent diet changes- all dentition in tact - no evident slap fractures of teeth Current Meds:- Annual vaccinations UTD- Desexed and wormed regularlyLifestyle Risk Factors:- Lives with another American Staffordshire Terrier (10 years old, described as full on)- Possible altercation between the two dogs suspected as potential cause of lesionOther:- Not typically a pruritic dogEXAMMentation: BARBehavioural: Gentle, sweet natured dog. Strong but cooperative during examination. Accepts treats readily.Integumentary: Round, raised, inflamed skin lesion present. Patient wearing Elizabethan collar due to pruritic behaviour and scratching at lesions.ASSESSMENTSkin lesions - DDx: insect bites, inter-dog trauma vs mass with 2ndary infection. Significant inflammation present making definitive diagnosis difficult at this time. recommend 1 week tx then re-visit for lump FNA if still present. PLANNew Meds/Tx:- Anti-inflammatory medication prescribed for home administration- Topical (neocort) treatment containing cortisone and local anaesthetic for application to affected areas to reduce inflammation and provide pain reliefAdditional Discussion:- Recheck appointment recommended in one week to assess response to treatment- If lesions resolve completely, no further action required- If lumps persist after inflammation subsides, fine needle aspirate planned to rule out mast cell tumours or other neoplasia- Continue Elizabethan collar use to prevent further self-trauma from scratching    Vital Signs