C09991408 / invoice 10000

Reason: Tumour removal

Physical Exam: See attached "Flowsheet Report"

Laboratory Results: See attached. All WNL.

Patient Assessment:

Patient Treatments:

Medications - See attached "Flowsheet Report"

IV Fluid Therapy - See attached "Flowsheet Report" 

Anaesthetic Record  -See attached "Smartflow Anaesthetic Sheet"

Surgical Record:
5mm red raised mass L of prepuce. Excised via an elliptical incision to include >5mm margins. Placed in formalin to send for histopath.
Sutured s/c layer with 3/0 PDS using a simple continuous pattern.
Intradermal sutures placed with 3/0 biosyn.
  
Plan:
Medication to go home with:
Carprofen from tomorrow morning. 75mg BID 5 days.
Wound check 10-14 days. 

Discharging Nurse/Vet:

Reason/concerns:  
Lump has appeared on ventrum, near penis

History:
Loves to sunbathe

Pre-existing Conditions / Medications:
- No pre-existing conditions noted at the time of examination
- No medications currently being provided at the time of examination

Preventative Healthcare: Vaccination and parasite (flea, intestinal worms, heartworm).

Examine: 
Mentation: BAR
BCS:       3/5   
MM: Pink          
CRT: 1-2 seconds
HR:        ~100                     beats/min
RR:      panting                       breaths/min
Temperature:              not taken today

Ocular: No abnormalities noted on cursory examination of both eyes.
Oral/Dental stage: Minimal calculus observed.
Ears: No abnormalities noted on cursory examination of both ears.
Cardiovascular: No audible murmur or arrhythmia and no difficulty hearing the heart. HR = PR and no evidence of hypoperfusion.
Respiratory: Respiratory rate and effort considered normal for the patient.
Gastrointestinal: No pain on abdominal palpation. No masses or abnormalities palpated.
Integumentary: Small ~5mm raised dark brown/black lesion on prepuce. 
Musculoskeletal: Normal gait and strength noted. No evidence of lameness.
Urogenital: No significant abnormalities noted during routine physical examination.
Neurological: No evidence of neurological impairment or altered mentation. Detailed neurological examination not performed today.
Lymph nodes: Within normal limits for mandibular, prescapular and popliteal examination.

Problem List:
Soft tissue mass

Patient Assessment: 
Concern for haemangiosarcoma due to Milo's signalment and lump's location. Advised surgical removal and histopathological analysis.

Diagnostics performed (i.e. bloods, radiographs/ultrasound, ear cytology, urinalysis):
None performed 

Treatment with medication 
dose rates (if any):

Client Communication
& Plan: 
Warned O that similar masses can occur in the future, often UV stimulated if haemangioma/haemangisarcoma. 
Mentioned getting dog friendly sunscreen to apply to areas of skin that are thinly covered in fur.