C10011775 / invoice 10000

lump on face for check

Subjective
Presenting Concerns:  
Snooki presented for evaluation of a new black spot below her left eye. The owner was concerned this could be skin cancer. The owner had questions about the pink appearance of her snout.  
  
Diet/Appetite:  
The owner reports Snooki is on a commercial diet that has improved her skin.  
  
Drinking/Urination:  
The owner notes that Snooki is reluctant to go outside to urinate on wet grass or in the rain but does not have accidents in the house.  
  
V/D/C/S:  
A single episode of regurgitation occurred in the exam room after eating treats.  
  
Skin & Coat:  
The owner is concerned about a black spot below the left eye and the pinkness of her snout. They apply a sun stick to her nose for protection. The owner also questioned if she has developed more black spots on her skin since adoption.  
  
Additional Information:  
The owner reports that Snooki is settling in well and is much more comfortable. They are working with a trainer on recall. She wears a GPS tracker.

Objective
Mentation: Bright, alert, and responsive  
BCS: 5/9  
T: Not taken  
R:24  
MM: pink/moist. CRT < 2sec.  
Hydration: Normal  
  
Emotional Assessment: The patient was initially a bit nervous but accepted liver treats readily. A marked improvement in anxiety was noted compared to the previous visit; she appeared much more comfortable, relaxed, and confident. She allowed full handling and examination.  
  
Eyes: Mild epiphora was noted from the left eye. The third eyelids were slightly prominent. Ophthalmic examination revealed a single long hair on the lower eyelid of the left eye, which was manually removed. The epiphora appeared to resolve following removal. The right eye was unremarkable.  
Ears: Clean with no discharge or erythema AU.  
Nose: The dorsal muzzle has a normal pink appearance, consistent with a white-coated dog with thin fur in this area. No evidence of excessive erythema, irritation, or lesions.  
Oral: NAD 
Cardiovascular: No murmurs or arrhythmias, strong synchronous pulses.  
Respiratory: Normal bronchovesicular sounds bilaterally.  
Abdominal: A small volume of regurgitation was noted after the patient consumed treats. No organomegaly or mass effects. No pain on palpation.  
Lymph Nodes: No peripheral lymphadenopathy.  
Integumentary: The black spot below the left eye was examined and identified as a normal tactile hair follicle (vibrissa). A similar follicle was palpated on the contralateral side. The skin and coat are in excellent condition with no evidence of ectoparasites.  
Neurologic: No ataxia, normal mentation.  
Musculoskeletal: Ambulation normal, no lameness observed.  
Urogenital: Normal external anatomy.  
Rectal: Not performed.

Assessment
Ocular irritation, left eye - Resolved. Caused by a foreign body (hair) on the lower eyelid, which was removed during the examination.  
Normal tactile hair follicle - The owner's concern about a black "lump" below the left eye was identified as a normal anatomical structure. Reassurance was provided that this is not a concern for neoplasia.  
Behavioral improvement - The patient shows a marked reduction in fear and anxiety, indicating successful acclimation to her new home and predictable routine.  
Otherwise apparently healthy - The remainder of the physical examination was within normal limits.

Plan
Medications/Treatments:
-   Monitor the left eye for any recurrence of watering. The owner was advised to contact the clinic if epiphora persists, at which point a topical eye medication may be dispensed.
-   Monitor the tactile hair follicle for any changes in size or appearance, though this is not anticipated.
  
Diet & Feeding Recommendations:
-   Continue the current diet as it appears to be beneficial for her skin and coat.
  
Additional Discussion:
-   Reassurance was provided to the owner that the findings on the skin (follicle) and nose (pinkness) are normal.
-   The owner was commended on their excellent care, which has resulted in a significant improvement in Snooki's confidence and a reduction in her anxiety.
-   Continue using the sun stick on the nose as needed for sun protection.(LM)