C09998326 / invoice 10000

Reason: Sore Paw NQGAP ONLY HISTORYFirst clinical signs - RHL lameness, chewing all four pawsSummary - Grade I MPL bilaterally, reluctant on bilateral hip extensionDiagnosis - Grade I MPL bilaterally, mild hip discomfortTreatment - Nil, to monitor at home, pain medication if more episodes of discomfortDiet: Preventative healthcare:Vacc:HWP:IW:Flea/tick:HISTORY:O's presenting complaint(s): Examine:PHYSICAL EXAMINATION: BCS: ## / 9MCS: normal muscle mass #Mentation: alert and responsiveEYES: NAD - clear, no noted discharge #EARS: NAD - clear, no discharge, odour, erythema#NOSE: NAD - clear, no discharge, symmetrical, no lesions #ORAL: NAD - normal pink and moist mm, normal CRT, healthy teeth & gums#CARDIOVASCULAR - NAD - no murmur or arrhythmia auscultated, pulse pressures normal and synchronous#RESPIRATORY: NAD - thoracic auscultation clear sounds bilaterally, respiratory effort normal#ABDOMINAL: NAD - soft pliable, no detectable pain or palpable abnormalities#NEURO: NAD - neurologically no significant findings, no cranial nerve or proprioceptive deficits/gait#MUSCULOSKELETAL: NAD - ambulating with normal gait & posture, no pain on palpation of joints, appropriate ROM#RECTAL: not performed#REPRODUCTIVE: externally normal #INTEGUMENT: NAD - clear coat and skin #LYMPH NODES: NAD - peripheral nodes palpate normal #Assessment:Plan:Diet: Preventative healthcare:Vacc:HWP:IW:Flea/tick:HISTORY:O's presenting complaint(s): Examine:PHYSICAL EXAMINATION: BCS: ## / 9MCS: normal muscle mass #Mentation: alert and responsiveEYES: NAD - clear, no noted discharge #EARS: NAD - clear, no discharge, odour, erythema#NOSE: NAD - clear, no discharge, symmetrical, no lesions #ORAL: NAD - normal pink and moist mm, normal CRT, healthy teeth & gums#CARDIOVASCULAR - NAD - no murmur or arrhythmia auscultated, pulse pressures normal and synchronous#RESPIRATORY: NAD - thoracic auscultation clear sounds bilaterally, respiratory effort normal#ABDOMINAL: NAD - soft pliable, no detectable pain or palpable abnormalities#NEURO: NAD - neurologically no significant findings, no cranial nerve or proprioceptive deficits/gait#MUSCULOSKELETAL: NAD - ambulating with normal gait & posture, no pain on palpation of joints, appropriate ROM#RECTAL: not performed#REPRODUCTIVE: externally normal #INTEGUMENT: NAD - clear coat and skin #LYMPH NODES: NAD - peripheral nodes palpate normal #Assessment:Plan:Diet: Preventative healthcare:Vacc:HWP:IW:Flea/tick:HISTORY:O's presenting complaint(s): Examine:PHYSICAL EXAMINATION: BCS: ## / 9MCS: normal muscle mass #Mentation: alert and responsiveEYES: NAD - clear, no noted discharge #EARS: NAD - clear, no discharge, odour, erythema#NOSE: NAD - clear, no discharge, symmetrical, no lesions #ORAL: NAD - normal pink and moist mm, normal CRT, healthy teeth & gums#CARDIOVASCULAR - NAD - no murmur or arrhythmia auscultated, pulse pressures normal and synchronous#RESPIRATORY: NAD - thoracic auscultation clear sounds bilaterally, respiratory effort normal#ABDOMINAL: NAD - soft pliable, no detectable pain or palpable abnormalities#NEURO: NAD - neurologically no significant findings, no cranial nerve or proprioceptive deficits/gait#MUSCULOSKELETAL: NAD - ambulating with normal gait & posture, no pain on palpation of joints, appropriate ROM#RECTAL: not performed#REPRODUCTIVE: externally normal #INTEGUMENT: NAD - clear coat and skin #LYMPH NODES: NAD - peripheral nodes palpate normal #Assessment:Plan:?GAP ONLY HISTORYFirst clinical signs - Summary - Diagnosis - Treatment ---- 06/03/2026 17:15:15 AKS:Flea Prevention - Skipped on 05/11/2025Tick Prevention - Skipped on 05/11/2025Verified: NoSubjective:Diet: Mixed diet including raw frozen portions from vet (Big Dog brand), turkey-based dry food in morning, chicken and vegetable meals prepared at home. Patient will eat anything.Recent changes to diet: nilPreventative healthcare:Vacc: C3 vaccination due 2028, annual vaccination due November this yearHWP: IW: Milbemax - last given November, slightly overdue (3 monthly dosing)Flea/tick: HISTORY:O's presenting complaint/s: Intermittent lameness right hind limb - lifting leg briefly when first getting up, then walking normally. Episodes lasting few weeks on and off, noticed more prominently this morning.- 4.5 year old female dog owned since 8 weeks- History of occasional skipping/bunny hopping while running since puppy- Previous ear infections, now resolved- Previous dental procedure with tooth extraction and full clean under general anaesthetic- Very active dog, enjoys running and chasingAppetite: NormalThirst: NormalVomiting: NilDiarrhoea: Had diarrhoea today (unusual)Access to chemicals or toxins: Nil knownAccess to rodenticides: Nil knownCurrent medications: NilPrevious medical history: - Previous ear infections- Dental procedure with tooth extraction and cleaning- History of pruritic skin condition with paw lickingExamine:PHYSICAL EXAMINATION:Mentation: alert and responsiveEYES: NAD - clear, no noted dischargeEARS: NAD - clear, no discharge, odour, erythemaNOSE: NAD - clear, no discharge, symmetrical, no lesionsORAL: Some discoloration noted on teeth front and back, otherwise normal pink and moist mm, normal CRTCARDIOVASCULAR - NAD - heart sounds strong, no murmur or arrhythmia auscultated, pulse pressures normal and synchronousRESPIRATORY: NAD - thoracic auscultation clear sounds bilaterally, respiratory effort normalABDOMINAL: NAD - soft pliable, no detectable pain or palpable abnormalitiesNEURO: NAD - neurologically no significant findings, no cranial nerve or proprioceptive deficits/gaitMUSCULOSKELETAL: Weight bearing on affected limb, some reluctance on extension of right hind limb, bilateral patellar laxity noted - grade 1 medial patellar luxation both stifles, no severe pain responseRECTAL: not performedREPRODUCTIVE: externally normalINTEGUMENT: Some skin discoloration noted on paws, patient licks all four paws regularlyLYMPH NODES: NAD - peripheral nodes palpate normalAssessment:Problem List:- Grade 1 bilateral medial patellar luxation- Intermittent lameness right hind limb likely related to patellar luxation- Pruritic skin condition with paw licking- History of food allergies (suspected chicken sensitivity)Laboratory: Treatment:Plan:- Monitor lameness episodes - if worsening or more frequent, consider pain relief (Meloxicam) pending blood work to check kidney function- Consider radiographs if not responding to conservative management- Diet trial recommended - turkey protein only diet for 8 weeks (turkey dry food morning and night, or cooked turkey meat)- Eliminate all other proteins including chicken, beef, treats during trial period- Milbemax worming tablet to be given tonight- Return if lameness worsens or skin condition deteriorates- Consider Apoquel for pruritic condition if diet trial unsuccessful (more expensive option available)    Vital Signs