C10022555 / invoice 10000

Primary Presenting Complaint:Lump on headOther Complaint:History:Previous oral sarcoma treated with radiation therapy approximately 5-7 years ago in Sydney. Patient has been clinically well since treatment. Owner reports sensitivity to the area.    - Microchip - Y - mentioned owner getting microchip done previouslyExamination:Clinically stable patient with small dermal mass requiring cytologic evaluation    - Musculoskeletal - 3x3mm nodule on left dorsal aspect of head, non-painful, not pruritic, subcutaneous.     - wart on the L dorsal hip    Assessment:Small dermal/subcutaneous mass on left dorsal head in patient with significant oncologic history (previous oral melanoma). Cytology required to differentiate between benign sebaceous cyst and neoplastic process such as mast cell tumor.Problem List:- 3x3mm nodule left dorsal head- History of oral melanoma (treated with radiation 5-7 years prior)DDx:Sebaceous cyst (most likely based on size and presentation)Mast cell tumorOther cutaneous neoplasiaFollicular cystHistiocytomaDiscussed:Owner consented to FNA procedure. Discussed differential diagnoses including sebaceous cyst (most likely) and mast cell tumor given oncologic history. Explained that if sebaceous cyst, monitoring is appropriate unless it enlarges, ruptures into surrounding tissue, or becomes infected, at which point surgical excision would be curative. Owner understands cytology results expected in 24-48 hours and agreed to follow up Friday if not contacted. Owner expressed concern about recurrence given previous cancer history, which is understandable.Treatment Plan:FNA performed with two samples submitted for cytology. If sebaceous cyst confirmed - monitor for changes in size, rupture, or infection. If neoplastic - discuss surgical excision options pending cytology results.Ongoing Prescriptions:Next Visit:Follow-up call expected within 24-48 hours with cytology results. Owner to contact clinic Friday evening if no communication received.The above clinical notes were created with the assistance of Astro Scribe under the supervision of the consulting Vet.    Vital Signs    Weight: 13.6;