C10028367 / invoice 10000

check lump under neck nail
GAP ONLY

Gap Only summary: 
Primary concern: Lump on neck
Duration of issue: 2 months
Suspect ddx:  Bite vs foreign body vs lump vs other

H: Went camping and had two lumps with 2 little holes in it. Giving antibacterial wash. 

No V+ or D+. BAR, EDDU normal. No other concerns. 

Preventatives: 

O: MM colour pink. CRT = 1-2s.
Grade () dental dse.
SMLNs normal. All other LNs normal.
Eyes: Clear, no corneal lesions, conjunctivitis or ocular discharge.
Ears: Clean, no inflammation or infection. No evidence of mites.
Chest ausc: Normal sinus rhythm. No heart murmur or arrhythmias. HR: ()
Resp ausc: Normal - no abnormal resp. sounds. RR: ()
Abd palp: Comfortable on abdominal palpation. Soft and pliable. No evidence of masses or FBs. T: ()
Skin and Coat: Clean, healthy coat. No other derm. lesions.
Neurological: Normal gait and proprioception. Full neurological exam not performed.
Musculoskeletal: No pain on manipulation and palpation of bones, joints and muscles.
BCS: ()/5

A:
- Problem list:()
- Ddx. ()

P:
- ()

Worming, nails, check up

Thought they needed a worming needle/needed to see a vet. 

H: Will eat plastic sometimes, especially left out. Sometimes throat is scratchy from eating plastic. Poos are grey. 
Frothy green vomit 4 days ago, has been fine since. Still eating well. 

Physical Exam WNL. 

Dispensed Popantel, continue NGS. 
Nails too short to clip. 

History: 3rd puppy vacc

Eating and drinking well. 
Toielting well.
No Vomiting or diarrhoea. No other concerns from owner. 
Had some diarrhoea, gave some chicken and rice - resolved. 

Preventatives: UTD - NGS 

Diet:stopped the raw mince, tin of sardines with puppy kibble (blackhawk)

Physical Exam:
MM: pink/moist
CRT: <2 sec

Oral: normal deciduous dentition and occlusion. 
SMLNs normal. All other LNs normal.
Eyes: Clear, no corneal lesions, conjunctivitis or ocular discharge.
Ears: Clean, no inflammation or infection. 
Chest ausc: Normal sinus rhythm. No heart murmur or arrhythmias. HR: 120
Resp ausc: Normal - no abnormal resp. sounds. RR: 30
Abd palp: Comfortable on abdominal palpation. Soft and pliable. 
Skin and Coat: Clean, healthy coat.
Neurological: Normal gait and proprioception. Full neurological exam not performed.
Musculoskeletal: Ambulating well, no lameness observed. No pain on manipulation and palpation of bones, joints and muscles.
2x testicles palpated

A: fit for vaccination

Treatment:
1. C5 vacc given SQ (DHP + Bb/Pi)

P:
1. C5 vacc due in 12 months
2. Continue with prophylaxis at home  
3. 6 month puppy check