C10001910 / invoice 10000

Reason: L3- UWR/UWR- Anal Gland Abcess (Ruptured)Presented and seen by Dr  Michelle Hahm   @ Time/Date 2312 7/3/2026History:Recently been managed for AG abscessation, was on amoxyclav for 10d and fentanyl patch. Seemed quieter than usual, but eating readily. No CSVD, softer faeces has been occurring for the past month or so. Removed fentnayl patch the day after placement due to abnormal behaviour and likely sensitivity. Rechecked with RV a few days ago, AG expressed  more.Today noticed that there was visible swelling again over the RHS of anusNo prior scooting behaviourNo straining to defecateDiagnosed as a diabetic a year ago. Currentlyon glargine (toujeo) 3IU BIDLast blood work <6mo ago, DM well controlled, no concerns of renal / hepatic parameters acc to O.Examination Findings:General demeanour: BARTemperature: DNPCardiovascular: no murmur or arrhythmia, FP synchronous and adequate bilaterallyRespiratory:  no overt bronchovesicular sounds, normal effort, no cough/sneeze witnessedAbdomen: soft, doughy abdomen, no pain elicited, no. mass effectPeripheral LNs: WNLEyes/Ears: NSFIntegument: visible bruising over R AG region, visible soft tissue swelling over R rump area compared to L rump. Previous inguinal hernia. Partially reducible.Oral exam: NSF Musculoskeletal: comfortable on all ROM of limbs, spinal palpation, neck manipulation.  Gait: Normal, no lamenessNeurological: Normal mentation, CN normal, CP x 4 normalRectal exam: right anal gland small but very firm, nonpainful, cannot be expressed (feels almost scarred over), left anal gland empty. Proximal to AG, palpable weakened rectal wall on both sides, but RHS much weaker at 3 o'clock region, able to insert ~1cm of index finger in a small "pocket". Tender to touch.Initial Assessment:Perianal hernia, concerns of mild fistula from previous AG abscessation. Palpable swelling over RHS rump regionClient Communication:Advised of the additional rectal exam findings. To go on another course of ABx but may require surgical referral to discuss if sx indicated if repeated infections, or may need to try other medical management first. Given DM, likely more immunocompromised so suspceptible to infections. Treatment:O declined opioid pain relief due to concerns over side effects from fentanyl patch previouslyAmoxyclav 93.75mg PO BID for 5 daysMeloxicam 0.1mg/kg PO for 6kg dose SID for 3-5 daysSoft E-collarPlan:OutpatientRecheck in 4-5 days with RV    Vital Signs    Weight: 6.1;