C09986208 / invoice 10000

NURSE:
HISTORY: Sore foot about a week ago. Was red and licking at it a lot. Put the cone on him Back left leg. Did vomit last night Does have addisons 
EDFU normally 

-Diet scratch food and eureka treat 
-Env in./out 
-Comp none
-Prev nexgard spectra 
Current Meds: pred 1mg 1 tablet once daily 
florinef 1 tablet twice daily 
-Insurance?
SUBJECTIVE: BAR
OBJECTIVE: T=  MM pink  CRT <2 sec HR = 108bpm no murmurs or arrhythmias audible  FP good RR panting RESP: normal lung sounds bilaterally
BEHAVIOUR ASSESSMENT: Anxious but nice
BCS: 5/9
GIT: Grade 2 dental disease, abdomen comfortable
U/G: NAD
NEURO: NAD
M/S: NAD
SKIN: RHL has firm lump with scab approx  1.5cm on back of left leg. - inflammatory cells and occasional cocci. 
OPHTH: NAD
OTIC: NAD
LYMPH/N: Normal peripheral LNs
ASSESSMENT: Mass on LHL over hock - inflammatory reaction - insect bite reaction, FB, other vs neoplasia. No obviously neoplastic cells and appears inflammatory
Mild dental disease
Tx OPTIONS: 1. Surgical excision 2. Medications and monitor, option 1 if not resolving
TREATMENT: Home with prednisolone 2.5mg SID 5 days then 2mg SID 5 days then back to 1mg SID ongoing. Amoxyclav 250mg 1/2 tab BID and chlorhex to clean. Keep E collar on
PLAN: Recheck 1 week if not resolving and consider surgical excision if not improving
DISCUSSION:  If not resolving will require surgery. if doing this recommend dental scale at the same time (unlikely any extractions) 
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DISCHARGE Leo has been examined today for a lump on his back leg. We have taken a sample of this and found inflammatory cells. We are sending him home with some cleaner and some antibiotics. You have prednisolone 1mg tablets at home - we recommend giving 2 1/2 tablets twice daily for 5 days then 2 1/2 tablets once daily for 5 days then back to his 2 tablets once daily for 5 days then back to his 1 tablet once daily ongoing. Keep his E collar on to stop him licking. If it is worsening, not improving or not resolving have him reexamined and we will consider surgical removal. if doing this we would recommend cleaning his teeth also.  If you have any concerns or queries please do not hesitate to contact the clinic 

Relayed blood results to owner. Look stable so continue with current doses. 

NURSE: SF 
HISTORY: 

Has been doing okay as of recently energy wise. 
At times he does like nauseous and looks like he needs to vomit. Licks his lips. Happens very randomly. Does inhale carrot and cucumber when fed it and can vomit after eating it.

EDFU
Good appetitre and drinking alot, toileting normally 

-Diet Scratch and carrot and cucumbers 
-Env Indoor/Outdoor 
-Comp Nil 
-Prev Nexgard Spectra 
Current Meds: Florienef 1 tablet bid, Prednisolone 1mg 1 tablet sid in the pm 
-Insurance? No 
SUBJECTIVE: BAR 
OBJECTIVE: T= not taken   MM  pink CRT <2  sec HR = 100 No murmurs or arrhythmias audible  RR normal lung sounds   RESP: Panting 
BEHAVIOUR ASSESSMENT: Anxious 
BCS: 5/9
GIT: Teeth Grade 1 dental disease, abdomen comfortable, no obviously palpable abnormalities
U/G: NAD
NEURO: NAD
M/S: NAD
SKIN: NAD
OPHTH: NAD
OTIC: NAD
LYMPH/N: Normal peripheral LNs
ASSESSMENT: Addisons- stable. Grade 1 dental disease
Tx OPTIONS: 1. TAHP vs lytes only. Given has been stable will do latter 2. Consider GA and clean/scale
TREATMENT: 1st KC Vaccination 
PLAN: Last full blood test was in April of this year. Advise a yearly full blood test for Leo. Today we are just going to check his electrolytes 
DISCUSSION: Discussed dental health, discussed monitoring after vaccination, will call O on Monday with blood results. 
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DISCHARGE Mr Leo has had a check up and a vaccination today. We have taken some bloods to check his electrolytes and will contact you monday with these results. We will also send through an estimate for a dental clean under anaesthetic. He is a lovely boy and appears to be in good health.  If you have any concerns or queries please do not hesitate to contact the clinic