C09996760 / invoice 10000

HISTORY: Vacc + old age check
seems to be getting older - appetite normal, lost little bit weight
been normal at home-sleeping bit more but to be expected 
found small lump around shoulder blade - front shoulder - cannot find now 

BIB laurie
BIOP
EDDU normally
No v/d/c/s. 
Diet: 
Current medications: nil
Parasite control: nexgard spectra

EXAM:
BAR
MM pink and moist, CRT <2s, 
Teeth  , dental grade  /4
Eyes, ears, nose NAD
Hydration
HR  108 , no murmur auscultated, normal rhythm, normokinetic and synchronous femoral pulses
RR panting , lungs clear, normal effort
Peripheral LNs WNLs 
Comfortable on abdominal palpation, 
BCS  /9
Temp
MSK – 
Integument Subcutaneous mass R shoulder front - 8mm 
Neuro -

ASSESSMENT:
Problem list
1. Subcutaneous mass R shoulder front - offered cytology - O declined 
2. Old age check up  - weight loss - O would like bloods

Ddx
TREATMENT: BB - BATCH 5245060A EXP 14.4.27 Influenza - BATCH 5264018 EXP 25.02.27
in house BG: 5.4mmol/L

PLAN:

DISCHARGE: 
Mr Murphy came today for his annual vaccines. He did very well and is all up to date for another year. We did take some blood work from him today that we will send to the lab and call you with the results in a few days. Continue to monitor the lump on his chest and if concerned or if there are any changes to it we can bring him back in to take a sample. 

 If you have any concerns or queries please do not hesitate to contact the clinic 

owner requested gabapentin as will be going away again for 4 weeks soon. Did really well on this last time. 
NB owner also noted intermittently his back legs shake. Not sure if is just when excited ( like in clinic) or all the time. owner will monitor and report back.