C10014675 / invoice 10000

Reason: Check foot
History:
Going well
Licking at foot the other day - put cone and some betadine
Seems to have settled but doing it a little
Needs a blood test today as well as her vaccination if possible
Ongoing medical conditions - None
Current medications - None
UTD deworming/ectoparasite – Y

Examine:
Mentation: BAR, friendly
BCS: 5/9
MM: pink/moist    CRT: <2s
HR: 72                RR: pant 2+
Temp: Not performed
PLN: Submandibular, popliteal and prescap wnl
Eyes: 
 - R mid upper eyelid small mass present 1-2mm diametre, slightly facing inwards
 - no discharge or hyperaemia evident today
Oral: mild/mod dental grade, G1/C2
Ears: nsf
Cardio: reg no murmur
Resp: nsf, no increase in effort or sounds
GIT: no pain on palpation, no obvious mass effect, no fluid wave
Integ: 
 - soft mobile mass on RHS abdomen wall about 2-3cm diametre
 - mild erythema front R foot no other concerns
MSK: nsf, ambulatory x4, no obvious pain on palp
Urogenital: nsf, no discharge
Rectal: Not performed 

Problem List:
1/ Pododermatitis (mild, resolving)
2/ ALT elevation, bloods repeated today (marginal elevation previously)

Fit for vaccination
Intranasal KC + Injectable DHP (C3) (c5 overdue)
KC1 due 2027

Plan:
Elocon cream to affected foot twice daily until resolved

Follow-up:
Revisit INI or worsening

Reason: Courtesy phone call 
Nurse: NA 
History:
     Demeanour: BAR
     Eating/ Drinking:small amounts as directed
     Toileting: no further diarrhoea today
     Any concerns? no o happy with progress
     
Treatment:
     Medications being given: n/a
     Patient taking meds as prescribed? n/a

Assessment: Vomiting resolved, diarrhoea improving

Next Appointment: o to advise