C10024192 / invoice 10000

WEIGHT: 18.20
HISTORY: Hx:
-toe has continued to swell more and become more painful.
-well in himself

2 view X-ray L D5 : P3 has obvious boney lysis consistent with neoplasia, most likely SCC, but can't r/o other (MCT, STT).

P:
-amputat toe

WEIGHT: 17.60
HISTORY: Subjective
Presenting Concerns:
-   Oscar Goding presented for:

*an abnormally growing nail(LD5), 
*redness and licking of the lower abdomen and groin
*a heartworm prevention injection.
  
Historical Conditions:
-   History of recurrent skin issues, previously treated with Malaseb shampoo and other medications. Only started recently - in past yr. 
  
Skin & Coat:
-   The owner reports that one nail has been growing abnormally since last year.  The dog licks the toe & limps occasionally.
-   The owner has noticed redness around the penis and on the lower abdomen. The dog has been licking the area.
-   The owner notes the licking and redness occurs year-round.
  
Current Medications:
-   Has previously been prescribed Trazodone for anxiety related to kenneling.
  
Lifestyle Risk Factors:
-   Will be going to a kennel soon.
  
Additional Information:
-   The owner requested a refill of anti-anxiety medication for the upcoming kenneling.

Objective
Mentation: BAR  
Wt:17.6  
BCS: 6-7/9  
T: Not taken  
P: —  
R: —  
MM: pink/moist. CRT < 2sec.  
Hydration: Normal  
  
Emotional Assessment: Happy and social.  
  
Eyes: Clear. No discharge or erythema OU.  
Ears: Clean with no discharge or erythema AU.  
Nose: Clear, moist without discharge.  
Throat: No inducible cough upon tracheal palpation; no palpable masses.  
Oral: Calculus and gingivitis absent. No masses or other lesions.  
Cardiovascular: No murmurs or arrhythmias, strong synchronous pulses.  
Respiratory: Normal bronchovesicular sounds bilaterally.  
Abdominal: No organomegaly or mass effects. No pain on palpation.  
Lymph Nodes: No peripheral lymphadenopathy.  
Integumentary: Mild, dry erythema is present on the skin of the medial thighs and around the prepuce, consistent with licking.  
Neurologic: No ataxia, normal mentation.  
Musculoskeletal: An abnormally thick and long nail is present on one digit. The nail was trimmed short during the examination. On palpation, the affected digit feels thickened compared to the contralateral digit, and seems painful (dog reacted more on palpation of that toe than the other one) 
Urogenital: Erythema is noted around the prepuce.

Assessment
Abnormally shaped and growing nail (LD5) – DDx: Squamous cell carcinoma, fungal infection (onychomycosis), bacterial infection (paronychia), trauma. The affected digit feels abnormal on palpation, raising suspicion for an underlying neoplastic process.  
  
Pruritus with erythema of the ventral abdomen and inguinal region – The recurrent nature of the skin inflammation and pruritus is suggestive of an underlying allergic skin disease. A food allergy component has not been ruled out.  
  
Prophylactic care – The patient is due for heartworm prevention and requires situational anti-anxiety medication for upcoming kenneling.

Plan
Vaccinations:
-   Administered Proheart injection for heartworm prevention.
  
Pending Diagnostics:
-   Discussed performing an X-ray of the affected toe to investigate the abnormal nail and digit. The estimated cost for the X-ray is $190. The owner declined at this time and will monitor.
  
Medications/Treatments:
-   The abnormal nail was trimmed as short as possible.
-   Dispensed Prednisolone for skin inflammation and pruritus. Instructions: Give half a tablet once a day for 5 days, then half a tablet q second day for 5 doses. Other options, including Cytopoint and Apoquel, were discussed but declined due to cost.
-   Dispensed Trazodone for situational anxiety for kenneling.
  
Diet & Feeding Recommendations:
-   Strongly recommended a strict elimination diet trial for 8-12 weeks to investigate a potential food allergy as a contributor to the skin issues. A handout was provided.
-   Discussed specific hydrolyzed protein diets, including Royal Canin Anallergenic, Royal Canin Hypoallergenic, and Hill's Z/D.
  
Additional Discussion:
-   The owner was educated on the risk of squamous cell carcinoma of the digit, which can present as an abnormal nail. It was explained that the treatment often involves toe amputation. The owner was advised to monitor the toe closely and return for an X-ray if the nail continues to grow abnormally or becomes bothersome.
-   Recheck advised if there is no improvement or if concerns arise.

WEIGHT: 15.25
HISTORY: H: In for vacc.
O's husband also found a lump near the penis that he has been licking? Couldn't find the lump in consult, only thing I could see was a pustule on L side next to penis.
EDDU well, no V no D.
O said one nail was missed at last nail trim, and think nails weren't trimmed short enough?

Going into kennel for around 10 days. Need trazodone like last time, was on 100mg 3/4 PO SID last time.

E: BAR, very excited!! BS5/9, wiggly, some worn teeth, DS1 tartar, HR130, mmp

eyes, ears, nose OK
panting, no obvious heart murmur
lungs clear
abdo pal seemed comfortable (wiggly)

no lump seen near penis except 1x small pustule on L side of penis with mild erythema surrounding it

A: 1x pustule on ventral abdomen

P: Nobivac Bb/Pi SC given. Vacc cert printed to show he had triennial C5 last year and KC this year.
Cazitel 35mg 1/2 PO given in consult (gave with liver treats!)

dispensed trazodone 100mg x 12 to give 3/4 PO SID for kennel.

O to do malaseb bath on ventral abdomen BIW for 2 weeks, then monitor.
If itching, need apoquel/cytopoint.

brought to back as very wiggly, nurse trimmed LH digit 5 nail (only one that's long), others can't be trimmed further, explained to O