C10031886 / invoice 10000

has a lump on nose

Standard Consultation

Presenting Concerns:
Moosey, a 2-year-old dog, presented for evaluation of a lesion on her nose. The owner reports the lesion has been present for approximately 2 months. It initially appeared as a discolouration and has subsequently developed a palpable lump underneath. The owner has not noticed significant growth.

Historical Conditions:
History of allergies affecting the paws and muzzle, which flare up in warmer months.
The owner suspects some degree of vision impairment, which has reportedly been static since puppyhood.
A wart is present on one foot, which the owner believes may be related to Apoquel use.

Diet/Appetite:
Appetite is reported as normal. It had recently decreased but improved after a course of antibiotics for pododermatitis.

V/D/C/S:
The owner reports occasional, clear nasal discharge, not specific to one side.

Skin & Coat:
The primary concern is the nasal lesion, which is not reported to be pruritic or have any discharge.
History of atopic dermatitis causing inflammation of the muzzle and pododermatitis with weeping lesions, particularly during summer.

Current Medications:
Apoquel for management of allergies.
Cortavance spray used on paws as needed.
Recently completed a course of antibiotics for a skin infection on her paws.
Received gabapentin prior to today's visit for anxiety.

Lifestyle Risk Factors:
Primarily an indoor dog, with walks scheduled during early morning or late evening to limit sun exposure.
Has had limited contact with other dogs recently.

Additional Information:
The owner reports that Moosey is anxious with injections.
Sunscreen is applied to her nose, but she often licks it off.

Mentation: BAR
Wt: 42
BCS: 7/9
T: Not taken
P: 80
R: 24
MM: pink/moist. CRT < 2sec.
Hydration: Normal

Emotional Assessment: Anxious, but appeared calmer than usual, likely due to pre-visit gabapentin. Accepted treats during the examination.

Eyes: Clear. No discharge or erythema OU.
Ears: Clean with no discharge or erythema AU.
Nose: A discoloured, alopecic lesion is present on the nasal planum. The underlying skin feels thickened on palpation, but the lesion is mobile and does not appear to be fixed to deeper structures. There is no palpable discrete mass. The lesion appears similar to scar tissue. No nasal discharge is present.
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: No evidence of ectoparasites, full coat with clear skin. A small wart-like lesion is noted on one foot. The skin on the paws appears normal at present.
Neurologic: No ataxia, normal mentation.
Musculoskeletal: Ambulation normal, no lameness observed.
Urogenital: Normal external anatomy.
Rectal: Not performed.

Point of Care Diagnostics:
Tape cytology of the nasal lesion was attempted yeilding superficial skin cells, no marker of malignancy.

Nasal planum lesion Ñ DDx: Post-traumatic scar tissue, inflammatory lesion secondary to allergic disease, neoplasia (e.g., squamous cell carcinoma, mast cell tumour), immune-mediated skin disease (e.g., discoid lupus erythematosus), fungal kerion. The lesion has been present for 2 months and appears as a discoloured, thickened area of skin. Given the patient's fair skin, neoplasia is a concern, though the current appearance is most consistent with a healing scar.

Atopic dermatitis Ñ Previously diagnosed. The condition is reportedly managed with Apoquel, though flare-ups affecting the paws and muzzle occur during warmer months. The skin is currently quiescent.

Situational anxiety Ñ The patient displays significant fear and anxiety during veterinary visits, requiring pre-visit administration of gabapentin to facilitate examination.

Pending Diagnostics:
The owner will monitor the nasal lesion at home. They were instructed to take weekly photographs with a ruler for scale to track any changes in size or appearance.
Re-evaluate in 2 weeks, or sooner if any changes are noted.
If the lesion grows or changes in character, the recommendation is to proceed with a sedated examination to obtain a diagnostic biopsy sample. The challenges of obtaining a good sample from a small, mobile lesion on an anxious patient were discussed.

Medications/Treatments:
Continue Apoquel as previously directed for management of atopic dermatitis.
A nail trim was performed during the visit.

Additional Discussion:
The rationale for monitoring the nasal lesion versus immediate biopsy was discussed with the owner. This approach aims to avoid causing significant stress and trauma to an anxious patient for a lesion that currently appears benign, while having a clear plan for investigation if changes occur.
A photograph of the lesion was taken and added to the patient's file for future comparison.
Sun protection strategies were briefly discussed. The owner will continue to limit sun exposure during peak hours.