C09979412 / invoice 10000

WEIGHT: 8.40
HISTORY: Subjective
Presenting Concerns:
-   Rusty presented for evaluation due to acute episodes of yelping, reluctance to jump onto furniture, and general signs of discomfort. The owner also reports that he yelped after defecating during a walk and has been dragging his rear end.
  
Diet/Appetite:
-   Appetite is reported to be good.
  
V/D/C/S:
-   The owner reports that Rusty yelped after a bowel movement.
-   He has been observed dragging his butt.
  
Additional Information:
-   The owner noted that Rusty yelped while lying in his bed.
-   He was not interested in going for a walk.
-   He is hesitant to jump onto his favorite chair and needs to be lifted.

Objective
Mentation: BAR  
Wt: 8.4kg  
BCS: 5/9  
T: 38.1°C  
P: 116bpm  
R: —  
MM: pink/moist. CRT < 2sec.  
Hydration: Normal  
  
Emotional Assessment:
-   Appeared worried and was twitchy during the examination. An increase in HR was noted during palpation.
  
Eyes: Clear. No discharge or erythema in both eyes.  
Ears: Clean with no discharge or erythema in both ears.  
Nose: Clear, moist without discharge.  
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.  
Neurologic: No ataxia, normal mentation.  
Musculoskeletal:
-   Guarding was noted around the right cranial shoulder area.
-   Significant muscle tension was palpated on the right side, described as feeling "like a rope" compared to the left side.
-   The right hip felt slightly tight, but the range of motion was good.
-   The neck, shoulders, elbows, and distal limbs had a normal range of motion without a painful response.
-   The spine palpated as normal.
-   Gait analysis showed even weight-bearing on all four limbs.
Urogenital: Normal external anatomy.  
Rectal:
-   A digital rectal examination was performed and was normal.
-   The anus appeared externally normal with no swelling.
-   Both anal glands were full with normal-appearing contents and were expressed.

Assessment
Acute Myofascial Pain – DDx: Soft tissue strain/sprain, IVDD, referred pain, nerve root impingement. The primary clinical findings of muscle guarding, significant right-sided muscle tension, and pain upon movement are most consistent with an acute muscle strain.  
  
Anal Sac Impaction – Both anal sacs were found to be full on examination. This is the likely cause of the reported butt dragging and may have contributed to discomfort during defecation.

Plan
Medications/Treatments:
-   Dispensed Carflexin 20mg. Give 1 tablet by mouth SID for up to 7 days.
-   Dispensed Diazepam 5 mg tablets. Give 1/2 tablet by mouth BID for up to 7 days for muscle relaxation.
-   Anal glands were manually expressed during the consultation.
-   Dispensed a scented spray for his perineal area.
  
Additional Discussion:
-   The owner was advised that the course of medication is for up to one week, but treatment can be stopped sooner if clinical signs resolve.
-   It was explained that the muscle soreness is the likely cause of his pain and reluctance to jump.
-   Advised to be cautious when lifting Rusty to avoid causing further discomfort.

WEIGHT: 9.45
HISTORY: C5 vacc/proheart
Presenting Concerns:
-   Rusty presented for an annual wellness examination and vaccinations. The owner also reported concerns about scooting and occasional yelping when his ears are touched.
  
Diet/Appetite:
-   Fed 1/4 cup of Black Hawk dry food BID plus wet food
-   Receives occasional treats.
  
V/D/C/S:
-   Scooting observed at home.
  
Current Medications:
-   Worming prevention is up to date.
  
Additional Information:
-   Occasionally touches his ears and yelps.

Objective  
Mentation: BAR  
Wt: 9.45 kg  
BCS: 5.5/9  
T: Not taken  
P: 152  
R: --  
MM: pink/moist. CRT < 2sec.  
Hydration: Normal  
  
Emotional Assessment: Manageable for examination.  
  
Eyes: Clear. No discharge or erythema bilaterally.  
Ears: Clean with no discharge or erythema bilaterally.  
Nose: Clear, moist without discharge.  
Throat: No inducible cough upon tracheal palpation; no palpable masses.  
Oral: Mild tartar present on the upper canine teeth.  
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.  
Neurologic: No ataxia, normal mentation.  
Musculoskeletal: Ambulation normal, no lameness observed.  
Urogenital: Normal external anatomy.  
Rectal: Both anal glands were full and were manually expressed.

Assessment  
Overweight - BCS is 5.5/9, with weight gain since last visit.  
Full Anal Glands - Correlates with clinical sign of scooting.  
Mild Dental Tartar  
Otherwise apparently healthy.

Plan  
Vaccinations:
-   Vanguard administered in the left shoulder.
  
Medications/Treatments:
-   ProHeart injection administered in the right shoulder.
-   Anal glands were expressed in-clinic.
  
Diet & Feeding Recommendations:
-   Discussed weight management. Recommended reducing dry food slightly as also gets some wet food
-   Advised considering a transition to a lower-calorie dry food formulation.
  
Additional Discussion:
-   Discussed the function of anal glands and the reasons for impaction with the owner.

HISTORY: dispensed traz to trial for when Chili the pup comes over as he is not taking to him at all and is generally more anxious than the others esp with loud noises, people coming over etc.