C09991765 / invoice 10000

05/03/2026 CONSULT

REASON/CONDITION:
**DATE OF FIRST CLINICAL SIGNS

Nurse notes:

History:
**existing health concerns
- giving 1mL meloxicam and going well with L forelimb lameness
- every now and then back Left leg limps - after exertion when inlaws throw the ball
- noticed a big ulceration on bottom on jaw under tongue 5 days ago
- loves to chase and catch sticks

Patient Data/exam
TEMPERAMENT: lovely 
BEHAVIOUR/ CC EFFECT: x
WEIGHT/BCS: 5/9
NORMAL DIET:
EDUD?: n
**CURRENT MEDICATIONS/CONDITIONS: meloxicam 1.0mL PO SID
TEMP: 37.9
HR & SOUNDS / PQ: 120, no murmur
MM COLOUR & CRT: pink, 1 sec 
RR / LUNG SOUNDS: n
ABDO PALP: n
RECTAL: x
EENO: 
Mouth exam - large region of ulceration ventral to tongue rostral mandible. No LN enlargement. No mandibular assymetry
L ear - waxy debris - no otoscope today as long involved consult
DENTAL:x
SKIN: n
LNs: n
MSK: no lameness on exam today
NEURO: n
UROGEN: n

**Assessment/Problem list:
Ulcerated lesion ventral tongue rostral mandible - ddx : trauma from stick and secondary infection, neoplasia (ie SCC). 

Dx plan: biopsies and histo and c&S if not resolving within 2 weeks. 

Tx plan: meloxicam 2.1ml PO BID, paracetomol 375mg BID (can increase to 750mg QID if needed). Amoxyclav 500mg BID

Lab: chem 11 and CBC nsf

Communication/ future plan:
- r/v in at least 2 weeks, earlier if sore or if notice getting larger.
- Check Left ear at recheck 
- called FO and informed bloods all normal