C09983356 / invoice 10000

Reason: Lump/ Abcess On Shoulder Appointment Notes: cckpRunning a minute late could not find clinic - CCSFReason:HISTORY:Re-check lump on right side, under shoulder.Presented to Green Cross Cranmer last week for the lump. Aspiration performed, reported as fine.Owner noted increased licking of the area yesterday.On inspection by owner, hair loss and pus discharge were observed from the lump.Lump has become softer since last week.Vaccination was due but has been postponed.Current meds: noneVaccination: Not UTD.Parasite Prevention: UTD. Flea, tick and worm prevention mentioned as given.Pre-existing conditions: noneAccess to toxins eg. Rodenticide: noneEXAMINATION: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 1, some gingivitisAbdominal: no detectable pain on abdominal palpationRectal: not performedUrinary: NSFReproductive: NSFIntegument/Ears: A lump is present under the right shoulder, with associated hair loss and evidence of purulent discharge.Lymph Nodes: NSFEyes: NSFDemeanour/Behaviour: not discussedPROBLEM LIST:Draining cutaneous mass right lateral ventral thoraxDIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:Inflammatory lesion, no bacteria found DIAGNOSTICS:Fine needle aspirate of the mass was performed.Slide examined under microscope in-house.Findings consistent with inflammatory cells.ASSESSMENT:Re-presentation for a previously assessed subcutaneous mass on the right lateral thorax .Owner reports recent licking, hair loss, and purulent discharge.FNA cytology revealed inflammatory cells, consistent with previous findings.Lump noted to be softer on palpation.DDx includes inflamed cyst, abscess, or other inflammatory process.TREATMENT:Meloxicam oral liquid prescribed.PLAN:Administer 0.4 mls (0.05mg/kg) of Meloxicam orally once daily for 5 days.Monitor for any adverse effects such as vomiting, diarrhoea, or inappetence.Re-assess if clinical signs do not improve or worsen.Discharged home into owner's care.CLIENT COMMUNICATION:Discussed examination and FNA findings with the owner.Advised on the administration of Meloxicam liquid.Counselled on potential side effects of the medication and to cease use and contact the clinic if they occur.Plan to postpone vaccinations until the current issue is resolved.Advised this consultation is charged as a revisit.    Vital Signs    MMColour: P&M;       Weight: 4.11;       HeartRate: 180;       BodyScore: 5;       DentalGrade: 1;       RespirationRate: 60;       CRT: <2s;