C09972804 / invoice 10000

Reason: Limping - Gotten Better - Cytopoint - GAP ONLY TO INSURANCEO advises that the limp has gotten much better since Saturday, has been licking the paw however. Due for Cytopoint and 6 monthly HC Nurse: -vaccination UTDHISTORY:Presenting complaint: Right front paw lameness and swelling since FridayOwner reports Mila continues to lick at right front paw excessivelyLameness has occurred occasionally beforeSwelling noted on palmar side of paw, particularly around the larger central padAppears to have sustained a cut or injury to the area between toesOwner concerned about bad breath and dental healthCurrent meds: CytopointVaccination: UTDParasite Prevention: UTD. Pre-existing conditions: Grass allergies - previously severe when living on acreage, improved since moving to townhouseAccess to toxins eg. Rodenticide: noneEXAMINATION:Body Condition Score: 6/9Pain Scale (0-4): 0/4Hydration status (%): hydration clinically adequateCardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: neurologically no significant findingsMusculoskeletal: ambulating normally, no palpable neck, spine, limb or joint painGastrointestinal:- Oral: normal, no mouth pain, dental score (1-4): grade 2 - calculus build-up mostly at back teeth- Abdominal: no detectable pain on abdominal palpation- Rectal: not performedUrinary: NSFReproductive: NSFIntegument/Ears: NSFLymph Nodes: NSFEyes: NSFDemeanour/Behaviour: cooperative and well-behaved during examinationPROBLEM LIST:Right front paw injury with swelling and open wound between toesDental calculus requiring professional cleaningGrass allergies - currently well controlledDIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:Traumatic injury to right front paw with secondary inflammationDIAGNOSTICS:NoneASSESSMENT:Mila presented with right front paw lameness and swelling since Friday. Physical examination revealed swelling around the central pad on the palmar surface of the right paw and an area of open flesh between the medial digits consistent with a traumatic injury. The wound appears clean without signs of infection. Dental examination showed grade 2 calculus build-up typical for her age. Grass allergies remain well controlled on current Cytopoint therapy.TREATMENT:Meloxicam 2.5mg tablets prescribed - one tablet once daily with or after food for pain and inflammationChlorhexidine swabs dispensed for wound cleaning twice dailyCytopoint injection administered: 30mg SCRecommend inflatable collar to prevent licking and further trauma to woundMonitor wound daily for signs of infection, swelling, or dischargePLAN:Home into owner's careDaily wound monitoring with chlorhexidine cleaningUse inflatable collar to prevent lickingReturn if wound becomes more swollen, or shows signs of infectionDental scale and polish to be scheduled - estimate to be emailedPre-anaesthetic fasting required - no food from 8pm night before, water until morningCLIENT COMMUNICATION:Discussed wound care and importance of preventing licking to avoid bacterial contaminationExplained anti-inflammatory medication administration with food to prevent gastric upsetAdvised on signs requiring immediate veterinary attention including increased swelling or dischargeDental procedure discussed including anaesthetic risks and pre-operative requirementsEstimate for dental scale and polish to be emailed for consideration    Vital Signs    Weight: 26.9;       HeartRate: 130;       DentalGrade: 2;       RespirationRate: wnl;       Temperature: 37.4;       CRT: 1-2;       MMColour: pink, moist;       BodyScore: 6;