C10017999 / invoice 10000

Reason: Swelling, Lump  Appointment Notes: Bear is licking at the lump and seems to be quite uncomfortable EMPresetented of licking bottom area started last fridayNoted doing it after licking since grooming last yearEDUD nromal no vo rdNo other concerns from ONo medsExamination:BARMm;pm crt;<2sEENO:WnlHR:132 wnl RR:20Skin:wnlMSK"wnlAbdo: comofrt on pal wnlAG: 80% full both sides easy to expressCaudal tip of scrotum region noted 1 cm pink mildly raised region hairlessAssessment:Erythemic regionAllergy skin irritation vs histiocytoma vs othersInvestigation(might be contraindicated for FNA as can cause more inflammation) vs sx investigation vs medication trialPlan:Discuss with O about poss ddxElected medication trialAtart on mometasone topical BID on the region and cone on for 1 weekExpect full recovery in a weeks time, if not recheck and consider investigation.    Vital Signs    Weight: 9.5;       

Reason: VaccinationAppointment Notes: - BAHistory:Been fineUTD on treatmentsExamine: Mentation: BARPeripheral LN: NSFOral: MM pink, moist. CRT<2sEyes: Eyes clear, no redness or discharge. No evidence of pathological ocular changes on external exam. Full ophthalmic exam not performed. Intact palpebral and menace response both eyesEars: Ears clean. No evidence of inflammation or discharge on external exam. Otoscopic exam not performed.Cardiovascular: Heart rate 120. No murmur or arrhythmia on auscultation. Pulse quality good and synchronous.Respiratory: RR and effort WNL. Lung sounds clear all fields.Gastrointestinal: Abdomen soft and non painful on palpation. No obvious organomegaly or abnormalities. Rectal exam not performed.Ugen: NSFInteg: NSFMSK: Ambulating well. Full MSK exam not performed.Neuro: NSF, normal mentationTemp: 38.0Assessment: Healthy adultTreatment: Duramune C4 SC dorsal midlineBronchishield oral    Vital Signs    Weight: 9.4;       

    Vital Signs