C10000912 / invoice 10000

Reason: Vocalising In Pain WhenAppointment Notes: placing pressure on hind legs, still bearing weightRecord created by Heidi Health AI - reviewed and edited by Dr EVCHistory:- Whimpering when jumping on bed, back leg slipping out slightly- Hesitant to put paws up and climb- Started yesterday after morning walk which seemed normal- Reluctant to jump on bed this morning, pain response when attempting- Walking appears normal but hesitant to sit down- On fluoxetine for anxietyExamination:- Weight: 15.3kg- Normal range of motion in neck, no pain on flexion in all directions- Normal range of motion in left and right forelimbs, no pain on manipulation of joints- Normal range of motion in hind limbs, no pain or resistance to flexion or extension of joints- Normal proprioceptive response to knuckling test in both hind limbs- Pain response on firm palpation of lumbar dorsum, not strong overt reaction but turning to look and pulling away slightly from pressure, repeatable in same location- Attempted to jump with forelimbs up on table but stopped himself and was very hesitant halfway through movementAssessment:, Treatment: & Plan:1. Suspected lumbar back pain- Likely soft tissue trauma or potentially IVDD- No neurological deficits present- Metacam 15kg dose with food SID, shake before use- Exercise restriction: short leash walks acceptable for toileting and around block, no running, jumping, or playing with other dogs- Monitor for improvement over next week- Gradually reintroduce exercise if completely normal by end of first week- Stop Metacam if vomiting, diarrhoea, or black stool occurs- Medication duration: minimum 3 days, possibly 3-5 days depending on response- If no improvement or worsening, further investigation requiredAdditional Notes:- Emergency signs to watch for: severe weakness or paralysis in hind legs requiring immediate veterinary attention- Advanced imaging (CT scan) would be needed for definitive diagnosis    Vital Signs    Weight: 15.3;