C10001196 / invoice 10000

Reason: Walking Funny/ Off FoodAppointment Notes: Overdue remindersHISTORY:  Presenting for unusual behaviour overnight. At approximately 2 am, Hugo was reluctant to go outside, standing at the door for a prolonged period. When he did go out, he stood staring at the door for 20 minutes before coming back inside. He did not jump on the bed as usual and was hesitant to get off the bed. He initially refused breakfast this morning but did eat after the bowl was moved. The owner reports he seems better now than he did overnight. owners are concerned regarding tick paralysis, although had nexgard spectra on 22/02/2026. owners also saw a snake around the house and was worried he might of been bitten by a snake. owner notes he does have a sensitive stomach and will get occasioanl bouts of diarrhea. Current meds: noneVaccination: Not utd? done elsewhere?Parasite Prevention: UTD. NexGard SPECTRA.Pre-existing conditions: noneAccess to toxins eg. Rodenticide: none TRIAGE:HR: 120 bpmRR: pantingTemp: 38.8 degrees celciusMm:  pinkCrt: 1-2 secondsMentation: normalate food this morningDemeanour/Behaviour: bright and alert in consult today. jumping around when played with.  EXAMINATION:Body Condition Score: 8/9 - advised on weightloss, aim 38 kgPain Scale (0-4): 0/4Hydration status (%): hydration clinically adequateCardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronous, normal sinus rhythm present Respiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological:neurologically no significant findingsMusculoskeletal: ambulating normally, no palpable neck, spine, limb or joint pain, walking normally, jumping around in consult when stimulated to do so. Gastrointestinal:Oral: normal, no mouth pain, dental score (1-4): lvl 1, mild Abdominal: no detectable pain , masses or fluid wave on abdominal palpationRectal: not performedUrinary: NSFReproductive: NSFIntegument/Ears: NSF, very mild amount of debris in pinnae, ear canals clear. Lymph Nodes: NSFEyes: NSFDemeanour/Behaviour: not discussed PROBLEM LIST:Abnormal behaviour (reluctance to move, inappetence, but then ate)Weight loss (600g since July 2025) DIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:Rule out tick paralysis (unlikely given prevention and clinical signs)Rule out snake envenomation (unlikely given clinical signs)Minor musculoskeletal injuryMild gastrointestinal upset DIAGNOSTICS:None ASSESSMENT: Hugo presented for abnormal behaviour overnight. On examination, all vital parameters were within normal limits and no significant abnormalities were detected. Weight has decreased by 600g since last measurement in July 2025. Given his presentation and that he is up-to-date with effective tick prevention, tick paralysis is considered highly unlikely. The clinical signs are vague and non-specific at this stage. A watch and wait approach is appropriate. TREATMENT:  Discharged home. PLAN:Monitor at home for the next 24-48 hours. If any new symptoms develop (e.g., vomiting, weakness) or if his behaviour does not return to normal, a re-evaluation and diagnostic workup will be initiated.Home into owner's care. CLIENT COMMUNICATION:Discussed that the clinical signs are non-specific. Advised that tick paralysis and snake bite are very unlikely due to his parasite prevention and the progression of signs. Explained that possibilities include a minor injury or mild gastrointestinal upset. Advised owner to monitor closely and to return for re-assessment and further diagnostics if he does not improve or deteriorates over the next 24-48 hours. Discussed weight and goal of reaching approximately 38kg.--- 03/03/2026 16:05:03 PM MDR:Examinations - Resolved - SMS sentMN    Vital Signs    Weight: 42.5;