C09985396 / invoice 10000

Reason: SKIN TAGS APPEARED AGAINHISTORY:  Presented for assessment of two skin masses.A mass on the ear pinna appeared approximately two weeks ago, which has increased in size, subsequently burst and bled. It is now drying.A second small subcutaneous mass was noted by the owner on the contralateral side.History of similar skin lesions on his head and back previously.The owner notes a history of a sensitive gut since birth and previous skin infections consistent with eczema.Appetite and elimination are normal. Diet consists of home-prepared fresh low-fat chicken mince, low-fat dry food, puree and white rice. Current meds: Apoquel half a tablet every 1-2 days for management of pruritus.Vaccination: UTD. Next due May 2026.Parasite Prevention: Bravecto.Pre-existing conditions: Atopy, sensitive gastrointestinal system.Access to toxins eg. Rodenticide: none EXAMINATION: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): not graded- Abdominal: no detectable pain on abdominal palpation- Rectal: not performedUrinary: NSFReproductive: NSFIntegument/Ears: A drying, crusted lesion is present on the margin of the ear pinna. A small subcutaneous mass is palpable on the contralateral trunk. The coat and skin appear otherwise healthy.Lymph Nodes: NSFEyes: NSFDemeanour/Behaviour: Anxious but compliant for examination. PROBLEM LIST:- bleeding Dermal mass,  R ear pinna- Dermal s mass, R trunk - keratin- History of atopy/eczema- Recommended dental scale and polish DIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:Dermal masses  - ddx benign vs maligant  rule out histiocytoma, infectious vs neoplastic process. DIAGNOSTICS:None ASSESSMENT:  Presented for evaluation of two skin masses. One mass on the ear pinna has a history of bleeding and is in an awkward location which may pose challenges for healing post-excision due to the risk of flapping. The second mass is a small subcutaneous lesion. A procedure under general anaesthesia has been planned for surgical excision of the masses and for a dental scale and polish. TREATMENT:  Discussed applying Betadine or an iodine-based solution to the ear lesion to keep it clean and aid drying until the procedure. PLAN:Scheduled for general anaesthesia for surgical excision of skin masses and a dental scale and polish on 11/03/2026.Admission scheduled for 9:30-10:00 am.Discharge planned for 5:00 pm.Pre-anaesthetic instructions provided: fast from food from the morning of the procedure; water is permitted.A nail trim will be performed while under anaesthesia.Home into owner's care. CLIENT COMMUNICATION:Discussed the plan for surgical excision of the masses and a dental scale and polish under general anaesthesia.Discussed the potential for healing complications for the ear lesion due to its location on the pinna margin, including bleeding post-operatively.The owner was advised to fast the patient from the morning of the procedure. The owner will bring his specific food for post-operative recovery to avoid gastrointestinal upset.The owner intends to claim the procedure on pet insurance. The estimated cost for the dental procedure is approximately $700. GapOnly payment will be processed at the end of the day.Consent has been given by the client to proceed with this treatment  -  Yes/No Plan:History-Update:Consent has been given by the client to proceed with this treatment  -  Yes/No    Vital Signs