C10032480 / invoice 10000

Record complete Y/N

Reason/concerns:  New nasal mass

History:
 - O notes 5 days ago noted new lump on nose.
 - No previous issues, first episode occurring.
 - Otherwise, no other major concerns.
 - EDUF WNL. occasional vomit (eats rocks). no D+.

Pre-exisitng Conditions / Medications: None

Examine: 
Mentation: BAR
BCS:               3            /5   
MM: Pink          
CRT: 1-2 seconds
HR:       120                      beats/min
RR:        panting                     breaths/min
Temperature:     NE

Ocular: No abnormalities noted on cursory examination of both eyes.
Oral/Dental stage: Some gingivitis and calculus observed.
Ears: No abnormalities noted on cursory examination of both ears.
Cardiovascular: No audible murmur or arrhythmia and no difficulty hearing the heart. HR = PR and no evidence of hypoperfusion.
Respiratory: Respiratory rate and effort considered normal for the patient.
Gastrointestinal: No pain on abdominal palpation. No masses or abnormalities palpated.
Integumentary: 2mm by 2mm raised erythematous lesion on mid left of nose. Otherwise NAD.
Musculoskeletal: Normal gait and strength noted. No evidence of lameness.
Urogenital: No significant abnormalities noted during routine physical examination.
Neurological: No evidence of neurological impairment or altered mentation. Detailed neurological examination not performed today.
Lymph nodes: Within normal limits for mandibular, prescapular and popliteal examination.

Problem List:


Diagnostics performed (i.e. bloods, radiographs/ultrasound, ear cytology, urinalysis):
- FNA pending results

Client Communication & Plan: 
 - Pending FNA results - told O FNA might not be able to ID baseline cells as not 100% definitive. Will require excisional biopsy for definitive diagnosis.
 - Monitor for time being.

Reason:  Vaccination
History: Full recovery from swimmer's tail after being seen by PVE.

Current medications: no

What Preventative health cover is being used and do you need to purchase any today?
UTD- monthly Simparico trio. 3mthly allwormers

Examine: 
Mentation: BAR, anxious but OK if approached slowly
Body condition score: 3/5
MM:       pink         CRT: <2sec
HR:  100              
LN: NAD
Temperature: NT 

Ocular: NAD
Oral/Dental stage: 1
Ears: NAD
Cardiovascular: NAD
Respiratory: NAD
Gastrointestinal: NAD
Integumentary & lumps (measurement, location): NAD
Musculoskeletal: NAD 
Urogenital: NAD
Neurological: NAD

Assessment: 
Healthy to vacc

Treatment: 
Nobivac Flex DHPPI 2515101 Exp 1/27
Nobivac Bb 2516202 Exp 1/27

Plan: 
CC vacc due in 12mth.