C09991223 / invoice 10000

Hx:No improvement. O followed the plan as per last consult wiht the malaseb, neocort, flamazine etc. No improvement to vulva. Still very swollen in appearance. Ruby not too bothered by it- only a small amount of increase in licking today. Still urinating normally, no changes. O feels her caudal mammary glands are more prominent than they used to be. Always had a pigment spot to the nipples, but now they stick out more. Seems fine otherwise. PE:Vulva still very swollen and prominent. Skin is not at all inflammed (potentially very mildly inflammed/lichenified at last visit). Skin looks soft and supple but wrinkled (suspect due to the creams). No erythema. No discharge. Caudal nipples bilaterally are slightly more prominent, with perhaps slightly more mammary tissue palpable beneathHas a subcutaneous lump near her left shoulder region- possible lipomaLump in right inguinal region, may have grown slightly, present some time - consdier FNA. Plan:Further investigation warranted for swollen vulva + subjective changes to caudal mammary tissueSS will send an itemised cost estimate to owner with plan for next steps on investigation. Consider under sedation:- FNA lump in right inguinal region (if unable to diagnose in-house, consider external cytology)- ultrasound of genitourinary tract- +/-  bloods for AMH testing (in case of possible ovarian remnant syndrome, but very unusual)- +/- fresh cystocentesis urinalysis- +/- visualise within vagina as far as capable with otoscopeO worried about cancer etc. Can decide on the +/- steps depending on the findings of preceeding tests.SS emailed o with estimate and proposed plan "Hi Allison!As we discussed, please find attached the cost estimate for Ruby. Dr. Marcus is happy to complete her genitourinary ultrasound within our clinic. She will require sedation and thus will need to fast from food from 10pm on the night prior to her procedure. My recommendation is:- ultrasound of genitourinary tract, looking for tumours in particular (this is the sedation + hospital + ultrasound fee)- fine needle sample the lump on her right side in front of her back leg (this is the FNA +/- cytology lab fee)- if indicated by the findings we may recommend a urine sample to be collected directly from her bladder for analysis (cystocentesis and analysis fee)- if indicated by findings we may recommend an AMH blood test, which looks for remaining gonadal tissue (also known as ovarian remnant syndrome), although this would be an unusual presentation in her age. To book in for this further investigation, please phone the clinic on 9764 4116."

Hx:No change since starting the medications and cleaning of the vulva region. Noticed a couple of times after she urinated, when owner gently wiped her vulva with toilet paper, there was a small amount of mucus (odorouless) present. Not scooting. Lickign vulva region a little bit. No straining or changes to urination pattern. PE:Periulva/vulva external skin still obviously swollen, with slight thickening of the skin, some hairloss. Within outer vagina region there is no obvious swelling, redness or discharge. Anal glands - left about 3/4 full of normal, easy to express yellow liquid; right empty. Free-catch urine sample-USG 1.043pH 7protein 1+WBCs 3hpfRBCs 2hpfSuqamous epithelial cells 1-2hpfNon-squamous epithelial cells 6-10hpfSediment exam just revealed increased squamous cells, minimal RBCs and no WBCs. No bacteria. No crystals. Plan:UTI appears resolved. Still vaginitis/vulvitis symptoms. Treating topically- malaseb wash twice weekly- clean twice daily gently with warm salty water to prevent cream build up- flamazine bid for 10days - neocort, 30min after flamazine, bid for 3 days, then sid for 7days. INI in 10days, revisit. May need to consider further diagnostics to investigate genitourinary tract at this time, including ultrasound. 

 Inhouse WBCs 11/hpfcloudy SG 1.031PH 7leu 2+GLU -ket -prot -BIL - Blood-no crystals.Left message to say start the prescribed medications and call if any concerns.