C09979098 / invoice 10000

HISTORY
Presenting for: Roxy presented for follow-up of anal sac issues

Historical Conditions:
- Large anal sacs identified on flush/examination last week, recommended for surgical removal by NL
- Chronic inflammation in anal sac area - Pt has allergic skin dz
EDUF all normal 

EXAM
Mentation: BAR
Behavioural: Relatively comfortable, not showing signs of distress
Rectal: Left anal sac not expressing at all today, possible palpable material in sac but cannot be certain if scar tissue or contents. Right anal sac expressed tiny amount of dark brown, gritty material so duct is patent. Significant scar tissue palpable in region. Patient relatively comfortable with minimal inflammation around perineum currently.

ASSESSMENT
Anal sacculitis with impaction - Left anal sac non-expressing, possibly re-impacted vs just scar tissue persisting. Right anal sac expressing minimal dark brown gritty material. Significant scar tissue formation secondary to chronic inflammation. High risk of recurrence given chronic nature and anatomical changes.

PLAN
Additional Discussion:
- Referral letter to be written for anal sac removal surgery
- Discussed surgical risks including post-sx faecal incontinence, infection, post-operative pain due to highly innervated area, but benefits of permanent resolution. Feel Sx removal is indicated for this patient.
- Specialist consultation may be delayed, advise O will need to keep close eye on P as I am VERY concerned the left anal sac abscess will immediately recur, recommend re-expression next Friday
- Surgery recommended due to chronic inflammation, risk of tumour development, and recurrent impaction issues
- May need to continue ABs before Sx 
- If long wait, could consider topical steroids but will seek guidance from WAVES (do not want to interfere with post Sx healing)
- Client expressed concerns about cost and insurance coverage limits - advised to ask for written estimate, and send to insurance for pre-approval

TTPONALM to see how Roxy is doing after procedure. SMS sent through after BT