C09996736 / invoice 10000

Reason: Oral massSurgery for oral mass biopsy + descaleHistory: Examination: Assessment:   Laboratory:   Sedation/premed:Anaesthesia: Induced with  ml of Alfaxan titrated to effect. Intubated with size   cuffed/uncuffed ET tube. Maintained on iso/02. Breathing circuit used: I.V. fluids: Placed 22g/20g Catheter in L/R cephalic.Placed on 5ml/kg/hr throughout procedure. BP monitored. Total fluids given: Surgery:    Dental radiograph to confim integrity of underlying bone/tooth (106)Mass appears to involve the buccal gingiva of 106. Wedge biopsies takenCalled Owner to discuss 106 extraction in order to allow narrow margin gingivectomy of lesion.Ow consentedGingival flap created.106 extracted and marked alveolar bone burr to maximise clean margins. GIngva closed with PDS3-0. Minor scale and polish whilst under GAAssessment:106 gingival lesion - Suspect benign neoplasia - submission of tissue for histopath to confirm106 prophylactic extraction due to mass present - extraction required to allow mass margins and closure of gingival flap. Treatment:  Withhold metacm injection until late PM as last oral dose 7:30pm last nightPlan:Soft foods for 7 days Abx prophylactically - recommended due to underlying heartmurmur    Vital Signs    Weight: 49;       

Appointment Notes: Overdue remindersClient Present: siobhan Pre-consult nurse: MollyVaccination status: reminder says due for KC?Flea & Tick prevention: nexgard spectraWorming: as above Heartworm: as above Other medication: no Diet: Dry in AM/PM  - farmers market chicken, loves carrots and dental chew. Cooked chicken - NO BEEF. Has been putting milk in food since this the weekend. Microchipped: details on file VIP:Insurance: yes BUPA details on file EDO (Trupanion):Liked eating prime100 treats mdHistory:Re-presenting for a change in the appearance of a known oral mass on the top right jaw. The mass is now more cauliflower-like. This is associated with a recent change in eating habits, increased dribbling, lethargy, and weight loss. There is also a history of a heart murmur and reduced exercise tolerance.    Patient Status: Stable  Current Diet: Eating soft food as he is reluctant to eat dry food.  Current Medications: Starting Meloxicam today.  Parasite Prevention: Not discussed  Vaccination Status: Kennel cough vaccine overdue since August 2025. C3 vaccine due 23/03/2026.  VetLove VIP: The VIP program was discussed, including benefits and costs. The owner is considering signing up.    EDUD: Abnormal  Vomiting/Diarrhoea: Absent    Owner Observations:-   The growth in his mouth has changed to a cauliflower-like texture.-   He did not finish three meals in a row over the weekend.-   There is an increased volume of dribbling.-   He is more lethargic.-   He has lost weight.-   Exercise tolerance is reduced; he lasts a maximum of 5 minutes on the beach.-   He pants a lot.Examination:Mentation: BAR  Wt: 45 kg  T: Not documented  P: Not documented  R: Not documented  MM: pink/moist. CRT < 2sec.  Hydration: Normal  Eyes: Corneas/irises/lenses/sclera/conjunctiva/palpebrae no significant abnormalities. (Anterior/posterior chambers and fundus exam not performed)  Ears: Clean, no inflammation  Nose: Clean  Throat: No tracheal sensitivity; no palpable masses.  Oral: A firm, cauliflower-like mass approximately 15-18 mm in diameter is present over the right maxillary fourth premolar (106). Mild plaque is noted on the mandibular incisors.  Cardiovascular: Grade 3-4/6 systolic heart murmur, loudest over the left hemithorax.  Respiratory: Normal bronchovesicular sounds bilaterally.  Abdominal: No organomegaly or mass effects. No pain on palpation.  Lymph Nodes: No peripheral lymphadenopathy.  Integumentary: Clean full coat. No lesions.  Neurologic: No ataxia, normal mentation.  Musculoskeletal: Ambulation normal, no lameness observed.  Urogenital: Normal external anatomy.  Rectal: Not performed.Diagnostics:Planned:-   Pre-anaesthetic blood panel (haematology and biochemistry).-   Repeat cardio proBNP test.-   Surgical biopsy of the right maxillary oral mass for histopathology.-   Dental radiograph of the right maxilla.-   Possible fine needle aspirates of the regional lymph node if prominent during the procedure.Assessment:-   Progressive right maxillary oral mass with associated inappetence, ptyalism, and weight loss.-   Grade 3-4/6 heart murmur with reported exercise intolerance.-   Overdue for kennel cough vaccination.    Differential Diagnoses:-   Oral mass: Malignant neoplasia (e.g., squamous cell carcinoma, melanoma) versus benign lesion (e.g., epulis).-   Cardiac: Progressive degenerative valve disease.Treatment:Meloxicam oral suspension (32 mL bottle) dispensed. To be given SID with food, dosed for a 45 kg body weight.Plan:-   An anaesthetic procedure is planned for an excisional biopsy of the oral mass, histopathology, and dental radiographs. The risks associated with anaesthesia given the heart murmur were discussed.-   The option of referral to a specialist centre was discussed and declined at this stage.-   A procedure has been tentatively scheduled for 06/03/2026.-   Pre-procedure sedation with trazodone and gabapentin will be administered at the clinic on the day.-   An estimate of approximately $1800 was provided. With the VetLove VIP program, the cost would be reduced to approximately $1400.-   The owner was advised to contact Bupa pet insurance for pre-approval.-   The owner is considering signing up for the VetLove VIP program and was advised to do so before the end of February to allow today's visit to be included.-   Interim pain relief with Meloxicam has been initiated.-   Vaccinations (C3 and Kennel Cough) will be updated at a later date.    Follow-up:  Admission tentatively scheduled for 06/03/2026 for the oral procedure. The owner will confirm the booking after contacting their insurance provider.Nurse Recall Plan:Nurse: Unspecified  Timing: Call 1-2 days post-visit    Status Check:-   EDUD: Check for any improvement in appetite with Meloxicam.-   Post-visit concerns: Check for any adverse effects from Meloxicam (e.g., vomiting, diarrhoea).-   Response to treatment: Enquire if he seems more comfortable.  Follow-up:-   Follow-up questions: Has the owner contacted the insurance company? -   Future appointments booked: Dental procedure tentatively booked for 06/03/2026.  Vet Flag:  If there are any adverse effects to medication or a worsening of clinical signs.--- 19/02/2026 10:33:52 AM MD:Examinations - 18/02/2026 10:19:48 AM MD Deferred: await till thursday to let metacam kick in md Resolved - Client telephoned - no answer. sent sms md    Vital Signs    Weight: 49.8;