C09993139 / invoice 10000

Appointment Notes: MH limp  ------- Sms reply: YESHISTORYPresenting for: Gracie presented for left leg lameness that has occurred a couple of times, with flicking of the leg noted last night, and ongoing ear issues.Skin: Ears have been bothering her on and off for a long time. Shaking her head a bit but not scratching excessively. No odour or discharge from ears.Current Meds: Cytopoint last given 3 months ago.Lifestyle Risk Factors: Sleeps on owner's bed at night and has a bed in the wardrobe. Jumps up and down from bed regularly. Owner is training her to sleep in her own bed to reduce jumping.Other: Recently gave a cry when in the backyard near the fence area. Owner removed lavender bush due to rat activity and concern about potential bites. Takes fish oil supplement.EXAMHR: 120MM/CRT: pink moist <2sResp: pantingBehavioural: Cooperative for examinationEars: Both ears clean on otoscopic exam, ear drums intact, no inflammation or discharge.Musculoskeletal: Left shoulder stiffness noted on manipulation and extension. Some generalised stiffness consistent with early arthritis changes.  Paws NADIntegumentary: Some scratching noted around ear area causing hair damageASSESSMENTLeft shoulder soreness - likely strain from jumping, possibly exacerbated by early arthritic changesAllergic dermatitis - chronic condition with current mild flare causing head shaking and periauricular scratchingTREATMENT Cytopoint injection 10mg SC batch #828805 exp 01/2027Meloxicam dog oral (1.5mg/ml) 6kg dose PO SID PRNPLANContinue fish oil supplement dailyAdditional Discussion:- If stiffness persists or worsens, particularly with cool weather or morning stiffness that improves with activity, consider arthritis injections (Zydax) course to slow progression- Encourage continued regular gentle exercise- Monitor for improvement with current pain managementClient Comms:- Advised to continue training dog to sleep in own bed to reduce jumping- Watch for signs of arthritis progression- Return if lameness doesn't improve with current treatmentF/U call in 7 days.    Vital Signs    Weight: 6.8;