C09998144 / invoice 10000

05/03/2026 Reason:
LEFT elbow
History: 
Generally is well.
Clinical based salient history: 
EDUF, no Vt or D 
No tenesmus
No PD or PU
Parasite prophylaxis utd 
current medications: none 

Examine:
Mentation:BAR
Body condition score: 5/9
Vitals/triage:
MM:pink moist,CRT: <2sec
HR:120 RR: ~40 Panting
LN: WINL
Temperature: NE - defensive
Ocular: no discharge or erythema 
Oral/Dental: NSF dental~ stage:0/4
Ears: no discharge or erythema 
Nose: externally normal , no discharges
Cardiovascular:no murmur or arrhythmia, pulses normal 
Respiratory:no abnormal lung sounds 
Gastrointestinal: mild splinting during exam but comfortable on abdo palp, no abnormal mass palpable 
Integumentary: no lesions, no signs of scales. no fleas or flea dirt. Pruritis score-0/10

Musculoskeletal:no gait abnormalities.
Neurological:No MS deficits in any of limbs, normal posture. Full neuro exam not performed
Urogenital: no abnormal discharges, externally normal.

Problem List:
Both the elbows have decubital lesions- hyperkeratosis hair staining and erythema
The left elbow has a prominent well isolated mass
Assessment/Treatment plan:
Based on purulent nature of sample started on cephalexin
Diagnostics discussed with O and treatment plan agreed to by owner:
FNA- sent to Nova vet for cytology
Treatment given/dispensed:
Cephalexin 600mg bid x 14
Next visit: Pending results we will most likely proceed to surgical excision of lump as is sizable and tumorous (bulging out)
O has ordered elbow guars- will use as unavoidably cannot isolate from hard surfaces