C09987070 / invoice 10000

HISTORY:Presenting complaint of progressive left hindlimb lameness.Bitten by an ant on the right hind foot on Sunday while camping.Started limping slightly on Sunday.By Monday, the limp was more pronounced and noted to be on the left hindlimb.The lameness has been progressively worsening.Owner suspects the pain is located in the hip/groin region.Owner noted the left hip appeared higher and more prominent last night.No obvious trauma or injury was witnessed.Plays roughly with another young dog at home.Current meds: noneVaccination: Not mentionedParasite Prevention: UTDPre-existing conditions: Retained testicleEXAMINATION:HR: 130RR: 20Mm: pinkCrt: <2sMentation: BARBody Condition Score: 5/9Cardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeEyes: No discharge, no redness, no blepharospasmEars: No discharge, no inflammationNeurological: neurologically no significant findingsMusculoskeletal: Non-weight bearing lameness of the left hindlimb. Pain elicited on manipulation of the left hip and extension of the left stifle. The hip feels to be in the correct position.Oral: grade 0Abdominal: no detectable pain on abdominal palpationIntegument: No parasites or inflammation notedUrinary: No significant findingsReproductive: No significant findingsLymph Nodes: No significant findingsPROBLEM LIST:Progressive, non-weight bearing left hindlimb lameness.Pain on manipulation of the left hip and stifle.DIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:Soft tissue injury (considered less likely due to progressive nature).Cruciate ligament injury (considered unlikely due to age).Hip pathology.DIAGNOSTICS:Radiographs of the left hindlimb (hip and stifle) under sedation are planned.ASSESSMENT:Presented for a progressive left hindlimb lameness of several days duration.The severity and progressive nature of the lameness are unusual for a simple soft tissue injury in a young dog.Examination reveals significant pain, but localisation is difficult between the hip and stifle.Further investigation is required to rule out significant orthopaedic injury such as a cruciate ligament tear or hip pathology, despite this being uncommon for his age.TREATMENT:Admit for sedation and diagnostic imaging.PLAN:Admit for sedation and radiographs of the left hindlimb (hip and stifle).The procedure is scheduled for around 12:00 pm on 04/03/2026 to allow for an appropriate fasting period.Await radiographic findings before determining further treatment.Contact owner with results and a plan post-procedure.CLIENT COMMUNICATION:The plan to admit Monty for sedation and X-rays of his left hind leg was discussed with the owner. The rationale for this investigation is the progressive and severe nature of the lameness, which makes a simple soft tissue injury less likely. The X-rays will assess the hip and knee to rule out conditions like a cruciate ligament injury, although this is considered unlikely given his age. The risks associated with sedation, though low in a young, healthy dog, were explained. An estimated cost for the procedure is $900-$1000. The owner consented to the plan, including emergency resuscitation if required, although this is highly improbable. Sedation: 0.15ml dom IVGood level of sedationXrays: Hips look dysplasticStifles NADPossible thickening of left stifle on palpation compared to right - no obvious difference on radsWill trial meloxicam for a weekIf not improving may need to consider referral to ortho    Vital Signs    Weight: 15.6;       

Appointment Notes: Booked Online: 10/10/2025 17:40:30 PMBooking Type: VaccinationBooking Notes: 16 week vaccination   ------- Sms reply: YReason: Client Present:Nurse:  ACHealthy Pets Wellness Testing: Done Yes / NoVaccination Type: due third puppy. Intestinal worming: ngsHeartworm Prevention:   NGS given last weekFlea Prevention: ngsTick control: ngsMicrochip:Insurance and Healthy Pets Plus:Behaviour concerns:Current medications: no Current Diet:  on Royal canin  puppy and minice r cooked ice vegies and vit powder. Type of Shampoo/Frequency:Toileting: no __________________________________________________________________________History:  Going well at home no concerns. Examination: PE/CE:BARBCS 7/9T: 38.3HR: 130RR: 24EENM: dental decid mm pink crt 1 ears nad eys nINTEG: NADMSK: Normal rom non painful in all 4 limbs.  ABDO: non painful no massesAssessment: Only 1 testicle today.  Recheck in 2 months. However possibly cryptorchid. Recommend cut back food, as overweight do not want to grow too quickly. Treatment: c4 sqConsent has been given by the client to proceed with this treatment  -  Yes/No Plan: continue ngs monthly. Ok for walks in 2 wks.--- 17/10/2025 10:21:30 AM ASD:Examinations - Resolved ---- 17/10/2025 10:21:32 AM ASD:Vaccinations - Resolved -    Vital Signs    Weight: 9.8;       

HISTORY:Presented for second puppy vaccination. BIOP for 3 weeks. He is settling in well. EDDU normally. Diet consists of Royal Canin dry food and home cooked food. Current meds: none.Vaccination: Presented for second vaccination.Parasite Prevention: NexGard spectra administered on 12/09/2025. Owner has NexGard Spectra at home for future use.Pre-existing conditions: R base narrow deciduous canine. Access to toxins eg. Rodenticide: none.EXAMINATION:BARDemeanour/Behaviour: FriendlyEyes/nose/ears: Clear and free of discharge.Oral exam: mm pink and moist; CRT <2s; Dental: R deciduous base narrow canine (mild) Cardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronous.Respiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal discharge.Abdominal: no detectable pain on abdominal palpation.Musculoskeletal: ambulating normally, no palpable neck, spine, limb or joint pain.Neurological: neurologically no significant findings.Integument: NSF.Rectal: not performed.Reproductive: Only one testicle palpable in the scrotum. Lymph Nodes: NSF.ASSESSMENT:- Fit for vaccination - Mild R base narrow deciduous canine - Suspected unilateral cryptorchidism (undescended testicle)TREATMENT:Vanguard C4 SQ.Vanguard B-oral PO PLAN:- Final puppy vaccination due in 4 weeks - Discussed ball therapy for base narrow canine - Re-assess for descent of the second testicle at the next visit.- Continue socialisation in a safe manner, avoiding dog parks and unvaccinated dogs until two weeks after the final vaccination.CLIENT COMMUNICATION:Discussed the vaccination and potential mild lethargy post-injection. Provided an information sheet on "ball therapy" for the base narrow canine, explaining it may help guide the adult tooth into the correct position. Advised to monitor for pain associated with the tooth. Discussed the importance of safe socialisation during this period, such as carrying Monty in public places or using a trolley. Advised to return in one month for the next vaccination. Microchip details have been updated by the owner.Reason: Nurse: -vaccination -heartworm -worming -flea/ticks Exam: Lab: Assessment: Treatment: Plan:--- 18/09/2025 11:31:18 AM CAM:Examinations - Resolved -    Vital Signs