C10016189 / invoice 10000

Reason: Lump Near Dew Claw LfAppointment Notes: twHistory:  Diet:EXAMINATION: HistorySignalment: 5yo male Staffordshire TerrierPresenting Complaint: Diesel presents for a mass on the left front legPatient History:- History of similar masses on front paws when younger that resolved spontaneously- Due for allergy injection (administered monthly as needed)- Has Neocort cream at homeExamVital Signs:Weight:26.0Temperature: WNLHeart Rate: 110Respiratory Rate: pantMucous Membranes: pink and moist CRT <2BCS: 3/5Findings:Eyes: NADEars: NAD externally - no otoscope exam performedNose: NAD, no discharge bilaterallyOral: NAD mm pm <2 - grade   /4 dental scoreHeart: NAD, reg rate and rhythm, no murmur auscultatedPulses: Strong and synchronousLungs: Clear lung fields bilaterally, no crackles or wheezes, normal resp rate and effortMusculoskeletal: No appreciable lameness, normal muscle mass/toneIntegument: *Raised firm plaque with superficial ulceration on medial aspect of left front dewclaw, evidence of licking/self-trauma* Also has some raised, inflamed areas between P4- P5 of LHL  - appears to be infected Peripheral Lymph Nodes: WNL on palpationAbdomen palp: Soft, non-tender, no masses or organomegaly appreciableUrogenital: Normal external genitalia, NADRectal Exam: Not performedNeurologic: Full neuro exam not performed. Neurologic status appears WNLAssessmentProblem List::- Mass on left front dewclaw - ddx histiocytoma, mast cell tumour- Possible secondary bacterial infectionPlanDiagnostics:- Fine needle aspirate performed: predominantly histiocytes and neutrophilsTreatment Plan/Medications:- Rx: Antibiotics for 7 days- Topical Neocort cream to affected area and back footCommunication::- Discussed differential diagnoses: histiocytoma (benign, self-limiting, common in dogs under 2 years) vs mast cell tumour (malignant, rapid growth, ulcerative)- Explained current mass characteristics suggest more benign category- Advised monitoring for trigger points requiring surgery: rapid size increase, irritation to patient, shape/colour changes- Recheck via phone call or text in 2-3 weeks- Client comfortable with conservative approach at this stageTREATMENT: AntiB'sPLAN:Recall 2 weeks    Vital Signs    Weight: 26;