C09992078 / invoice 10000

NQR

History: 
- O stepped on Milo accidentally last night (LH?), today yelping randomly and urinating himself 
- Still eating and drinking normally. No V/D. No coughing/sneezing. No access to toxins. 

Examination: 
- BAR, friendly. BCS 4/9. Dental 1/4. 
- HR 120bpm, no murmur, MMs pink/moist, CRT 1s, pulses normokinetic and synchronous. 
- RR WNL, clear bronchovesicular lung sounds bilaterally, regular rhythm.
- Soft/comfortable abdominal palpation. No obvious mass/organomegaly/fb palpable. 
- All peripheral lymph nodes wnl. Temp 39.5 degrees. 
- G2/6 lame LH, no obvious pain response elicited, G1/4 MPL, no appreciable bone injuries. 
- Proprioception/deep pain present x 4 limbs. No pain on spinal/neck manipulation. 
- PLR + menace present/consensual. Tail comfortable. 

Urinalysis: 
- USG 1.038. 
- Dipstick: 1+ blood (sucked off ground), otherwise NAD. 

Plan: 
- Suspect pain - TGH with loxicom 0.1mg/kg SID for 5 days + strict rest. 
- If no improvement with loxicom revisit for bloods next 24-48h. 
- If improvement then relapse when off loxicom rec sedated xrays to check HLs. 

Annual vacc C4 durammune & BB 1/3

History:
O reported that Milo has been well at home 
Displaying good appetite & energy level 
UTD with worming & flea control 

Exam:
BAR, BCS: 5/9, friendly 
Eyes: nad
Ears: nad
Mouth: pink MM, CRT<2s, grade 1/4 teeth 
CVS: HR wnl, no murmur or arrhythmias detected
Resp: RR wnl, no abnormal lung sounds
Abdo: abdomen comfortable upon palpation
M/S: nad
Skin: nad, good hydration
Temp: not taken 

Assessment: 
Healthy for vacc 

Plan: 
Gave C4 durammune inj SQ & BB oral 
Discussed desexing & provided estimate 

R eye infection 

History:
O reported that Milo's R eye has been producing green discharge today, pawing at area intermittently  
Otherwise displaying good appetite & energy 

Exam:
BAR, BCS: 5/9, happy boy but headshy 
Eyes: R eye has mucopurulent discharge 
             Blepherospasm, scleral congestion, fluorets -ve 
Ears: nad
Mouth: pink MM, CRT<2s, puppy teeth 
CVS: HR wnl, no murmur or arrhythmias detected
Resp: RR wnl, no abnormal lung sounds
Abdo: abdomen comfortable upon palpation
M/S: nad
Skin: nad, good hydration
Temp: not taken 

Assessment: 
R eye infection 

Plan: 
Home with amoxyclav & metacam courses as tricky to give eye ointment, headshy