C10011620 / invoice 10000

Lumps & Bumps
Lump/growth on chest not bleeding

HISTORY
Presenting for: Lacey presented for evaluation of a firm lump underneath her nipple and a growth protruding from her rectum.
Historical Conditions: Spayed early, before first heat cycle
Diet: Currently on specialized diet including quinoa, pumpkin, kale, and multivitamins as prescribed by nutritionist
Current Meds: No current medications mentioned

EXAM
Mentation: BAR
BCS:5/9
HR:88
R: 28
MM: pink
Hydration: good
Behavioural: sweet girl
Eyes: nad
Ears: Small sore noted on ear
Nose: Minor abrasion from jamming nose under gate
Throat: nad
Oral: nad
Abdominal: nad
Lymph Nodes:nad
Integumentary: Firm, hard lump located underneath nipple with purulent discharge upon examination. Black skin tag attached by thin stalk at perianal region. Small follicular lesion on back consistent with folliculitis. Minor rash on nose from trauma.
Rectal: Large black skin tag protruding from perianal area, attached by thin stalk
Diagnostics: Examination of mammary mass revealed purulent discharge consistent with abscess formation

ASSESSMENT
Mammary abscess - Folliculitis with secondary bacterial infection and cyst formation underneath nipple
Perianal skin tag - Benign appearing, pedunculated lesion
Folliculitis - Minor skin condition affecting back and other areas

PLAN
New Meds/Tx:
- Cephalexin (Cef) BID for bacterial infection treatment of mammary abscess and folliculitis

Additional Discussion:
- Mammary cancer very unlikely given early spay status
- Skin tag removal optional if becomes ulcerated, irritated, or problematic
- Mammary abscess may resolve with antibiotics or may enlarge and rupture naturally
- Monitor lesions for changes in size, irritation, or patient discomfort
- Surgical removal available if lesions become problematic