C09980680 / invoice 10000

Reason: Courtesy SMS sent

Reason/concerns:
Over past 5-6 days, Os noticed several things
1) reluctant to use stairs
2) mandible was hanging down, like she couldn't close mouth, since resolved
3) leaky eyes, both eyes
4) 3rd eyelid protruding

Eating well, drinking the same, no v/d, no c/s
Os started 4cyte recently

Pre-existing Conditions / Medications:
- No pre-existing conditions noted at the time of examination
- No medications currently being provided at the time of examination

Preventative Healthcare: Vaccination and parasite (flea, intestinal worms, heartworm).

Examine: 
Mentation: BAR
BCS:    3/5   
MM: Pink          
CRT: 1-2 seconds
HR:       108                      beats/min
RR:      panting                       breaths/min
Temperature:              38.6C

Ocular: Epiphora L>R. Very minor 3rd eyelid protrusion. Enophthalmos L eye. 
Oral/Dental stage: Some gingivitis and calculus observed.
Ears: No abnormalities noted on cursory examination of both ears. Clean otoscopy. 
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: No significant abnormalities.
Musculoskeletal: Gait skittish/disorientated? Fully ambulatory. No evidence of lameness.
Urogenital: No significant abnormalities noted during routine physical examination.
Neurological: Head tilt to L side. Absent lateral palpebral reflex L eye, medial present both eyes. Menace, dazzle ok, PLRs ok. 
Lymph nodes: Within normal limits for mandibular, prescapular and popliteal examination.

Patient Assessment: 
Explained to O that I think something neurological is going on. Ddx Horner's syndrome / cranial nerve (V/VII?) disease / intracranial lesion. Summer isn't unwell or in pain, so ok to monitor, signs may improve/resolve by themselves. Os happy to monitor but aware referral may be required. 

Diagnostics performed (i.e. bloods, radiographs/ultrasound, ear cytology, urinalysis):
None performed 

Treatment with medication 
dose rates (if any):
None today

Reason: sore RF on rising 
History: slow when getting up after periods of rest, mainly RF paw, then warms out of it. Has been doing for last few weeks
- fine with walks, no limping 
- change in diet seems to be helping 
- otherwise doing well 

EDUF: all normal, no v/d

Diet: O has changed to Hills metabolic mobility

Current medications: none

Vaccination: UTD
PP: monthly chew UTD 

Examine: 
Mentation: BAR
Body condition score: 3/5
MM: PM               
CRT: 1-2s
HR:                
RR: panting 

Ocular: clear, no discharge 
Oral/Dental stage: 2/4- mild calc and gingivitis 
Cardiovascular: no m/a
Respiratory: no abnormal lung sounds 
Gastrointestinal: soft, comfortable 
Integumentary & lumps (measurement, location): NAD- no external wounds, lumps or skin lesions evident RF. Nails a little long  
Neurological: all CPs WNL

Musculoskeletal: 
- resistant to hip extension bilaterally- possible anxiety component 
- no stifle crepitus or effusion palpated, ok for flexion and extension
- ok for carpal, elbow and shoulder flexion and extension bilaterally 
- could not palpate any masses or any specific areas of pain RF- although MSK exam difficult as did not like paws being touched 

Assessment: 
Sore RF on rising- RF NAD on exam today; possible hip pain. DDx: most likely DJD- disc rads to r/o other underlying dz, O declined
Disc pain relief- O declined for now
Nails trimmed FL

Plan: monitor over next few weeks, discussed adding in 4Cyte, rv INI- will send OA vetcheck 
Consider gaba prior to future MSK appointments- discussed w O