C09972929 / invoice 10000

Reason: Laser Rec By ALC, Has Had Accupuncture BeforeAppointment Notes: ktReason: History: Current Medications:Senior: discuss if needed.Vaccinations up to date ? Examine: Diet: Dental/oral cavity: Eyes: Ears: Cardiovascular/respiratory: GIT/abdomen: Urogenital: M/skeletal: Skin: Lumps: Lymph Nodes: Behaviour: Assessment: Treatment: Plan: Script status:  Checked and updated? Yes/NoVaccination / Blood test / Catrophen Reminders up to date? ADJUST ACCORDINGLYRevist/ Recall/ Reminder:Verified: NoHistory:Presenting for: Lola, a 12-year-old female dog, presented for back issues with right hind leg stiffness that started approximately one week ago. Owner reports the leg goes stiff and she finds it hard to put it down, causing her to fall over a few times while playing.Historical Conditions:- Previous back issues diagnosed in 2020 with X-rays showing spondylosis- Has always exhibited intermittent behaviour of stopping while walking and putting one paw backwards since puppyhoodCurrent Meds:- Previcox - started approximately one week ago, owner reports minimal noticeable improvementSkin:- Hair loss over tail base area noted for approximately 6 months- No other coat changes reported by ownerOther:- Owner has reduced high-impact exercise (ball throwing) and switched to longer walks- Still maintains routine of wanting toy thrown after eating- Sometimes struggles to jump on bed and couch, though sometimes appears to pretend she cannot do it- Continues to show normal energy levels and appetiteExamination:Behavioural: Very good during examination, sits quietly and cooperates despite being terrifiedIntegumentary: Hair loss noted over tail base area consistent with 6-month history reported by ownerNeurologic: Normal proprioception - does not leave foot in abnormal position when testedMusculoskeletal: Right hind limb weight-bearing reduced, standing more on tiptoes on affected side rather than placing foot flat. Range of motion through hips not severely restricted for 12-year-old dog but some limitation present, likely combination of mild arthritis and muscle tightness. Palpation of lumbosacral disc spaces elicits discomfortDiagnostics: Blood sample collected for senior profile including total T4Assessment:Chronic lumbosacral spondylosis with suspected nerve compression - Most likely continuation of previously diagnosed spinal condition with progression causing intermittent nerve pinching episodes. Current episode of right hind limb lameness consistent with nerve compression in lumbosacral region. Normal proprioception suggests primarily pain-related rather than functional nerve deficit at this stage.Possible hypothyroidism - Hair loss over tail base in typical location for thyroid-related alopecia, though no other classic signs present.Plan:Diagnostics:- Senior blood profile with total T4 submitted - results expected tomorrow. Additional thyroid testing at external laboratory may be required if T4 results fall in grey zone (low normal range)- CT scan referral to Austin Veterinary Clinic, Malvern for definitive imaging of lumbosacral spine. Outpatient procedure under anaesthetic, estimated cost approximately $1400-1500. Will rule out more serious conditions such as spinal tumours and provide detailed assessment of nerve compression to guide treatment planningAdditional Discussion:- Laser therapy discussed as treatment option once imaging completed. Class 4 therapeutic laser penetrates 6-7cm deep, reduces inflammation and promotes cellular healing. Treatment course involves 2 treatments per week for 2-3 weeks initially, then spacing out based on response- Gabapentin available as additional medication option for nerve pain if Previcox insufficient- Owner advised current exercise modification appropriateClient Comms:- Will contact tomorrow with blood results- CT referral being sent today, clinic will contact owner directly to arrange appointment- Treatment plan will be finalised once imaging results available    Vital Signs    Weight: 16.4;