C09982628 / invoice 10000

Appointment Notes: Booked Online: 01/03/2026 15:28:47 PMBooking Type: Health CheckOwner Name: Enrique  Montecinos Owner Email: enriquemontecinos@gmail.comOwner Mobile Number: 0431858235Pet Name: ShadowPet Species: DogWeb BookingClient name: Montecinos Contact number: 0431858235Email address: enriquemontecinos@gmail.comPatient name: ShadowHISTORY:  Presented for assessment following an episode of apparent pain on Sunday. The owner reported Shadow was not walking up the stairs normally but has since returned to normal ambulation. The owner suspected a fall or jump may have been the cause. The episode involved vocalisation when being picked up under the skin on one side. He was subsequently able to be picked up by supporting the chest and hips without issue.Eating and drinking habits are normal. No vomiting or diarrhoea reported. Current meds: Panadol administered for the past two days.Vaccination: UTD. Due in December. Coronavirus is not current as the vaccine is no longer stocked.Parasite Prevention: Not mentionedPre-existing conditions: Generalised sensitivity and reactivity to handling, particularly abdominal palpation.Access to toxins eg. Rodenticide: none EXAMINATION:Very limited due to temperament - had to be muzzled Body Condition Score: 5/9Pain Scale (0-4): 0/4Hydration status (%): hydration clinically adequateCardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronous. Tachycardia noted, likely secondary to stress. No murmur auscultated.Respiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal discharge.Neurological: neurologically no significant findingsMusculoskeletal: ambulating normally, Gastrointestinal:Oral: normal, no mouth pain, dental score (1-4): not gradedAbdominal: significant sensitivity and guarding on abdominal palpation.Rectal: not performedUrinary: NSFReproductive: NSFIntegument/Ears: Ears contain a moderate amount of wax and hair, predisposing to infections. No significant erythema. Skin appears normal.Demeanour/Behaviour: Anxious and reactive during examination. Required a muzzle. PROBLEM LIST:1. History of acute, resolving pain.2. Marked abdominal sensitivity on palpation.3. Anxious, reactive temperament. DIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:Musculoskeletal pain (resolving).Possible underlying gastrointestinal sensitivity, e.g., pancreatitis or foreign material, though less likely given the absence of other clinical signs. DIAGNOSTICS:None ASSESSMENT:Shadow presented for a recent episode of pain that has clinically resolved. He is now moving normally and is bright and alert. Examination revealed marked sensitivity on abdominal palpation, though this is reported to be a chronic issue. Heart and lung auscultation were unremarkable. Given the lack of vomiting, diarrhoea, or inappetence, significant ongoing gastrointestinal disease is less likely. The original pain may have been musculoskeletal and self-resolved. TREATMENT:  Aloveen conditioner pack dispensed.Consultation fee waived. PLAN:Monitor at home.Continue to use Panadol as needed for any signs of discomfort.Re-present for further investigation, including bloodwork, if signs of pain recur and do not respond to Panadol, or if vomiting, diarrhoea, or inappetence develop.Home into owner's care. CLIENT COMMUNICATION:Discussed that while the original issue seems to have resolved, the abdominal sensitivity is a concern. Advised that without further diagnostics, the exact cause cannot be determined due to his reactive nature. Instructed the owner to monitor for any worsening signs, such as vomiting, diarrhoea, lethargy, or inappetence, and to return immediately if these occur as they could indicate a more serious issue like pancreatitis or a gastrointestinal foreign body. Advised to use Panadol for mild discomfort but to return if this is not effective. Total for today's visit is $55.30. Explained vaccinations are due in December.    Vital Signs    Weight: 12.7;       HeartRate: 144;       BodyScore: 6.5/9;