C09977259 / invoice 10000

Reason: Not Himself, Sore Back.Appointment Notes: Overdue remindersHISTORY:  Presented this afternoon for assessment of apparent pain and trembling. The owner noted the patient was shaking while on the couch at home. The trembling is reportedly worse in the clinic environment. There is no history of recent trauma, such as jumping or falling. Appetite and thirst are normal, with no vomiting or diarrhoea reported. Yelped and flinched when O went to pat his back.  Current meds: noneVaccination: UTD.Parasite Prevention: ProHeart SR12 injection administered in July 2025 for heartworm prevention. Owner was unsure about current flea and tick prevention but believes they may have a spot-on treatment at home. Counselled on the importance of regular flea and tick prevention.Pre-existing conditions: noneAccess to toxins eg. Rodenticide: none EXAMINATION:Body Condition Score: 5/9Pain Scale (0-4): Palpable pain noted over the mid-thoracic spine (just caudal to shoulderblades). The patient turned his head quickly and attempted to sit when this area was palpated.Hydration 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. Full range of motion in the neck noted on flexion, extension and lateral movements. Palpation revealed significant tenderness over the mid-thoracic region.Gastrointestinal:- Oral: normal, no mouth pain, dental score (1-4): grade 1- Abdominal: no detectable pain on abdominal palpation- Rectal: not performedUrinary: NSFReproductive: NSFIntegument/Ears: NSFLymph Nodes: NSFEyes: NSFDemeanour/Behaviour: Quiet but alert. PROBLEM LIST:1. Acute onset back pain.2. Mild dental tartar. DIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:Suspected intervertebral disc disease (IVDD) or soft tissue injury (muscle strain/sprain). DIAGNOSTICS:None ASSESSMENT:The patient presented for acute onset trembling and apparent pain. Examination revealed significant focal pain over the mid-thoracic spine, consistent with a soft tissue injury or early intervertebral disc disease. The patient is neurologically appropriate. The current lean body condition is beneficial. TREATMENT:  Prescribed Meloxicam (Metacam) oral liquid for anti-inflammatory pain relief for 5-7 days.Dosage: 5kg mark on the provided syringe once daily with food. PLAN:Strict rest for at least one week. No running, jumping (especially on/off furniture), playing, or roughhousing.Recommended using step stools or ramps to access furniture like beds and couches, or training the patient to wait to be lifted.Re-evaluation if signs worsen or do not improve with rest and medication.Home into owner's care. CLIENT COMMUNICATION:Discussed the presumptive diagnosis of a back injury, likely a muscle strain or a mild disc issue. Emphasised the importance of strict confinement and activity restriction to prevent worsening of the injury, particularly avoiding jumping. Instructed on the administration of Meloxicam with food and advised to monitor for any gastrointestinal upset. Advised on strategies to prevent jumping, including the use of steps/ramps. Discussed the need for ongoing, consistent flea and tick prevention.--- 03/03/2026 08:56:20 AM SKR:Examinations - Resolved -    Vital Signs    Weight: 5.5;       

Reason: VaccinationHistory: Presented today for annual vaccination. O reports EDDU well, no V or D. Flea, tick & worming: last given over 6m ago Examination: Demeanour: BARHydration: euhydrated MM: PM, CRT <2s Eyes: clear, no dischargeEars: clear, no dischargeMouth: C1G0, no mouth lesions Integument: smooth coat, no obvious ectoparasites or lesionsThoracic auscultation: normal heart sounds, no murmur or arrhythmias; normal lung sounds, no crackles or wheezes Abdomen: soft and comfortable on palpation Urogenital: clear, no dischargeMSK: weight bearing and ambulatory on all limbs, normal ROM Neuro: appropriate mentation, no obvious CN deficits Laboratory: In house heart worm test -> negative Assessment: Fit for vaccination & heart worm injection Treatment: C4 SQ between shoulder blades + BB oral 0.28ml SR 12 SQ between shoulder blades Consent has been given by the client to proceed with this treatment  -  YesPlan:Continue yearly vaccination & heart worm injection. Advised O can still give drontal every 3m for worming, but heart worm is covered for the year. O notes does not go out into bushes/grass much so relatively low risk for fleas and ticks.    Vital Signs    Weight: 5.6;