C10018980 / invoice 10000

HISTORY: eating and drinking good, lump on neck, discovered it last week. not bugging with it,. nmo conerns other than lump 
EDDU normally
No v/d/c/s. 
Diet: dry food and saussage roll from woolies 
Current medications: nil
Parasite control: bravecto 

EXAM:
BAR
MM pink and moist, CRT <2s, 
Teeth good, no abscesses noted , dental grade 2 /4
Eyes, ears, nose NAD
Hydration good
HR108  , no murmur auscultated, normal rhythm, normokinetic and synchronous femoral pulses
RR 42  , lungs clear, normal effort
Peripheral LNs WNLs 
Comfortable on abdominal palpation, 
BCS 6 /9
Temp
MSK –  10-15cm firm mass under right side of chin in sublingual LN region.
Integument – nad
Neuro - nad

ASSESSMENT: mass (ddx abscess vs salivary gland vs neoplasia vs other)

TREATMENT:
in house FNA cytology: lots of RBCs present, 1+ neutrophils, rare lymphocyte 

PLAN:
home with meloxicam and amoxyclav, monitor at home. if worse come in
recheck in 7 days 
FNA cytology sent to lab 

DISCHARGE: 
We saw Mr. Louie in her a lump under his chin. We did take a look at a sample under the microscope and found there to be some signs of inflammation so we are sending him home with anti-inflammatories (meloxicam) and antibiotics (amoxiclav). Please give these as prescribed. We are sending a sample of the lump to the lab. We will call you in the next few days with the results. 

In the meantime, please monitor the site and bring him back in sooner if it is getting worse. Otherwise, we will recheck him in one week. 

 If you have any concerns or queries please do not hesitate to contact the clinic 

owner came in to let clinic know ear mass has cleaned up

follow up. 
DE called to see how he is going. no answer. left message. if not improving then should be rechecked. 

still there but not bothering him (haven't put cone on yet) CW