C09975466 / invoice 10000

Reason: Waiting In Room1Appointment Notes: Mass On Foot Thats Opened Up NowVerified: NoHISTORYPresenting for: Rocky presented for evaluation of a mass on the back left foot that developed following previous ACL surgery and implant placement.Historical Conditions:- Previous ACL surgery with implant placement- Post-surgical scan revealed a mass in front of the implant, suspected to be infectious- Biopsy was recommended but client declined due to travel distance to Miranda- Current mass has been present for a couple of days, initially appeared to dry up on antibiotics but then began leaking againCurrent Meds:- Antibiotics for approximately 2 days prior to visit (course completed)- Gabapentin (given as calming medication during recovery)- Topical NeoCort cream- Pink disinfectant solution for cleaningLifestyle Risk Factors:- Anxious temperament, has seen a behaviouristOther:- Client managing multiple pets on medications concurrentlyEXAMBehavioural: Very anxious patient, required calming medication during previous proceduresIntegumentary: Mass present on back left foot with associated ulceration and bacterial infection. Inflammatory changes noted on surface examination.Lymph Nodes: Lymph node palpable but not significantly enlarged, indicating localised infection without systemic lymphatic involvementASSESSMENTInfected cutaneous mass on left hind foot - Bacterial infection confirmed, underlying mass aetiology undetermined without histopathologyPLANNew Meds/Tx:- Gabapentin 1/2 tablet once daily or BID as needed for anxiety and pain relief- Oral antibiotics 3/4 tablet BID for 14 days- Oral anti-inflammatory 3/4 tablet once daily for 10 days to reduce swelling- Topical antiseptic spray 2-3 times daily after cleaning (bitter tasting to discourage licking)Changes to Existing Meds/Tx:- Discontinue NeoCort cream due to steroid content which may impair healing- Continue pink disinfectant solution for cleaning - dab rather than scrubAdditional Discussion:- Discussed biopsy options: incisional biopsy under anaesthesia would provide definitive diagnosis, with potential second surgery for amputation if malignant- Conservative medical management chosen over surgical biopsy- Goal to treat infection and reduce ulceration to achieve stable, non-ulcerating mass that can be monitored- Continue topical treatment until normal skin colour returns, may continue 3-4 weeks as needed- Walking restrictions not required as patient prefers indoor environmentClient Comms:- Insurance claim to be submitted electronically- Total consultation cost $446.50- Monitor mass for reduction in size and healing of ulcerated surface- Return if mass enlarges, continues ulcerating, or fails to respond to treatment    Vital Signs    Weight: 35.4;       

Reason: Waxy right EarHistory: EDDU well. Red angry right ear, scratching and shaking headExamination: BAR, TPR= WNL, EENT: NSF, Oral cavity: dental tartar 2/4, CRT: <2 sec, mm pink and moist, Integument (skin/coat): NSF, H/L: no murmur or arrhythmias, regular rhythm, lungs clear, Peripheral lymph nodes: NSF, U/G: NSF, M/S: NSF, BCS: 3/5, Abdominal palpation: NSF.Assessment: overweight, otitis externa right earPlan: Cytology ++yeast, cocci+EpioticEasoticMetabolic dietClient Communication: recheck in 10 days    Vital Signs    Weight: 42;       HeartRate: 120;       BodyScore: 7/9;       RespirationRate: 32;