C10029021 / invoice 10000

REASON: Recheck RF paw + LN's
Nurse: CC
Presented by: Kerry & Andrew
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SUBJECTIVE / HISTORY: 
Some limping til Tuesday. None since. 
Been normal self at home. 
Charlie been licking at Lilly's R eye 

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CURRENT / ONGOING MEDICATION AND SUPPLEMENTS:
Finished abx this morning. 
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OBJECTIVE / EXAM:

Prescapular LN - barely palpable (>0.5cm)
Popliteal LN - small (>0.5cm)
Axilar - small (>0.5cm)

Some discharge from R eye. 

RF paw less inflammed. 
No hole. 
Faint thickening. 

n : Normal     - : Not Examined
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ASSESSMENT: 
Problems:
{__}

Ddxi:
{__}

Further Procedure & Diagnostic Needs [Client Response]:
{__}

Medication:
{__}

Ongoing medication prescriptions? Renewed prescriptions: {__}
[a] = Appointment     [d] = Deferred     [w] = Waived     [x] = Do it now
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PLAN / CE: 
O interested in chest rads and blood test if requiring second paw explore. 
Finalised by {__}
Rec = Recall     Rev = Revisit     Rem = Reminder

REASON: Recheck post xrays 
Nurse: SP
Presented by: Kerry + Andrew
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SUBJECTIVE / HISTORY: 
Foot still swollen but limping 90% better, Lilly has been licking paw
O noticed lumps in armpits
EDUD normally
Would like to treat Lilly palliatively
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CURRENT / ONGOING MEDICATION AND SUPPLEMENTS:
Amoxyclav 250mg 1.5 tablets BID - finished
Antinol
Gabapentin 100mg 1 capsule BID
Pentosan
trazodone for appt
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OBJECTIVE / EXAM:
ASA Status (1-5): 2
BCS (1-9): 5
DS (0-4): -

T: -
P: 100
R: n

APPEARANCE/DEMEANOUR: BAR
SKIN & COAT: Swelling improved on RF paw, small amount of purulent dischargepresent at wound between digit 2 and 3. Discrete mass medial aspect digit 3 unchanged, though not as painful today
EARS: n
EYES: n
ORAL: -
MM: Pink, moist
CVS: Normal rhythm
RESP: Lungs clear
ABDO/GIT: comfortable
UROGEN: n
NEURO: n
MSK: n
LN: R prescap 2cm popliteal 1.5cm, SMLN 1.5cm

n : Normal     - : Not Examined
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ASSESSMENT: 
Problems:
1. Mass on paw + infection
2. Enlarged LN

Ddxi:
infection vs neoplasia vs both

Further Procedure & Diagnostic Needs [Client Response]:
FNA LN [d] for now
Repeat AB course for 1 week

Medication:
Amoxyclav

Ongoing medication prescriptions? Renewed prescriptions: -
[a] = Appointment     [d] = Deferred     [w] = Waived     [x] = Do it now
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PLAN / CE: 
Rev 1 week recheck RF paw +/- FNA LN's +/- liver bloods
Rem 3m hc with vet + start Pentosan Course
Finalised by ALX
Rec = Recall     Rev = Revisit     Rem = Reminder

Post Op Recall
Going Well. EDUD normally. No O concerns.