C09974536 / invoice 10000

Reason: Recheck Mammary LumpAppointment Notes: Had mastitis 3 wks ago. Still the same size. Not feeding puppies. No milk pressent. BAR DUDEHISTORY:Missy, a one-year, five-month-old female entire Australian Shepherd Cross, presented for a recheck of a mammary lump.She whelped two puppies in early December and they were weaned a few weeks ago. The lump on her right cranial mammary gland was first noted after weaning.She was initially seen on 05/02/2026 for possible mastitis, presenting with a firm, non-painful swelling on the right cranial mammary gland with a small amount of bloody discharge expressed from the nipple. The medication course was finished approximately one week ago.Eating, drinking, and urination/defaecation are normal. She is behaviourally normal.Current meds: noneVaccination: Not mentionedParasite Prevention: Not mentionedPre-existing conditions: noneAccess to toxins eg. Rodenticide: noneDiet: Not mentionedEXAMINATION: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: normal, no mouth pain, dental score (1-4): grade 0- Abdominal: no detectable pain on abdominal palpation- Rectal: not performedUrinary: NSFReproductive: A firm, mobile, non-painful mass is palpable on the right cranial mammary gland. Two smaller pea-sized masses are palpable behind it.Integument/Ears: NSFLymph Nodes: NSFEyes: NSFDemeanour/Behaviour: Bright, alert, and friendly during examination.PROBLEM LIST:- Right cranial mammary mass (firm, mobile, non-painful)- Two smaller adjacent pea-sized massesDIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:- Mammary tumour-mastitis- Inflamed lump/galactoceleDIAGNOSTICS:A fine needle aspirate of the right cranial mammary mass was performed. A small volume of serosanguineous fluid was obtained.In-house cytology of the fluid revealed RBCs and epithelial calls but no concerning cells, but it was noted that mammary tumours often do not exfoliate well.ASSESSMENT:Missy is a young, entire female dog who recently whelped. She has presented for a persistent mammary lump. Examination revealed a firm, mobile mass on the right cranial mammary gland, with two smaller adjacent masses. Fine needle aspirate was non-diagnostic. The primary differentials include a hormonally-influenced benign lesion or a mammary neoplasm. Given her entire status, hormones are likely a contributing factor. The owner wishes to potentially breed her again.TREATMENT:None givenPLAN:Several options were discussed with the owner:1.  Desexing and complete excision of the mass with histopathology. This is the recommended option for Missy's long-term health.2.  Referral to a reproduction specialist for an biopsy and discussion regarding future breeding.3.  Conservative management: monitor the mass for two months. If it increases in size, persists, or spreads, surgical intervention (option 1) is strongly recommended.The owner has elected to monitor the mass for one month and will then proceed with desexing and mass removal if there is no change. An estimate for the procedure will be sent to the owner.Home into owner's care.CLIENT COMMUNICATION:Discussed the examination findings and the non-diagnostic nature of the FNA. Explained the possible causes for the mass, including hormonal changes post-whelping versus mammary cancer.Strongly recommended desexing and mass removal with histopathology to obtain a definitive diagnosis and prevent recurrence or development of further mammary tumours. Discussed the risks of future pregnancies, including the potential for the mass to grow under hormonal influence and the risk of requiring a caesarean section (estimated cost up to $4000).The owner was advised about pet insurance options, specifically the puppy plan with "Help Your Pet," which may offer discounts on desexing.The plan to monitor the mass for one month before proceeding with surgery was agreed upon. An estimate for the surgery will be provided. Advised to return sooner if the mass grows, changes, or if Missy becomes unwell.    Vital Signs    Weight: 23.9;       

Reason: Recheck Mammary LumpAppointment Notes: Had mastitis 3 wks ago. Still the same size. Not feeding puppies. No milk pressent. BAR DUDEConsult Time: History: Subjective: Objective: Temp            MM              CRT             HR             FPCV:  NADRESP:   NAD           RRGIT:   NADU/G:  NADNeuro:  NADM/S:  NADInteg:  NADOphth:  NADAssessment: Plan: Treatment: Consent has been given by the client to proceed with this treatment  -  Yes/No    Vital Signs    Weight: 23.9;       

Reason: Possible Mammary Lump OcAppointment Notes: Had a litter over christmasReason:- Presented for assessment of a mammary lumpHistory:- The owner reports a lump under one of her breasts, first noticed approximately two weeks ago- The lump has reportedly increased in size since being noticed- Missy whelped two puppies approximately eight weeks ago, in early December, and weaned them approximately four weeks ago- She is not reported to be bothered by the lump- There has been no impact on daily activities, she is still eating well and is happy and playful- No c+/s+/v+/d+- EDDU: ok- Parasite control: not mentioned- Pre-existing conditions: none- Current medications or supplements: none- Owner has no other concernsExamination:Body Condition Score: not examinedGENERAL: BAR, friendly temperament, hydration status - well-hydrated, mm pink and moist, CRT <2 secondsHEART: regular heart sounds, no obvious murmurs or arrhythmias, strong and synchronous peripheral pulsesRESP: lung fields clear on auscultation - no crackles or wheezing, normal effort and no obvious nasal dischargeEARS: external exam only - no discharge, no odour, no obvious inflammation or irritationEYES: clear chambers, no discharge, symmetrical pupilsABDO: soft and supple on palp, a firm, non-painful swelling was noted on the left cranial mammary gland, approximately 2cm in diameter, a small amount of bloody discharge was expressed from this teat and also from a teat on the right side with no associated swellingLYMPH NODES: no peripheral lymph node enlargement on palpORAL: no pus or discharge noted, not gradedMSK: good general conformation and ambulatory on all four limbs, patellas bilaterally firm, no hind dew claws, good range of motionINTEGUMENT: fur and coat in good condition, no ectoparasites on skinUROGENITAL: not examinedAssessment:- The primary differential diagnosis is mastitis, given the recent history of whelping and lactation- Trauma from nursing puppies is also a possibility- Mammary neoplasia is considered less likely due to her young age and the acute onset- A clotting disorder was considered due to the bloody discharge from multiple teats, but is less likely, client was questioned about potential toxin exposure (e.g. rat bait) and was unsure but reported no other signs of bleedingTreatment:- Amoxycillin/clavulanic acid prescribed 250mg, three-quarters of a tablet twice daily until finishedPlan:- Discussed the most likely diagnosis is mastitis- Discussed treatment options, including antibiotics and anti-inflammatories- Explained that anti-inflammatories would help reduce inflammation but antibiotics were the priority- Discussed the cost of treatment, client elected to proceed with antibiotics only at this stage ($217.30 for both, $146.30 for antibiotics alone)- Advised the client they could obtain the anti-inflammatory medication later if needed after a follow-up phone call- Instructed client on medication administration: three-quarters of a tablet twice a day until the course is finished- Advised to monitor the lump and to seek further veterinary attention if there are any changes or concerns- Advised a re-evaluation is recommended in one to two weeks to assess progress--- 06/02/2026 13:16:38 PM KCE:Examinations - Resolved - Sent Text KJC    Vital Signs