C10001876 / invoice 10000

Presenting Complaint:  Not acting himself, being tender on his back legs, esp right and been unsettled all night. Hurt his back last week and O gave meloxicam Orally for a few days. Skin flare up present again Weight 4.3kg today Awaiting patient history for vaccination status History-Appetite: ate well this morning, is a bit picky always -Thirst: normal -Urination: normal -Defecation: normal -Vomiting / diarrhoea: neg -Coughing / sneezing: no -Exercise tolerance: yes - normally doesnt want to be walked but carried -Behaviour changes: not himself-Weight changes: suspect drop in weightCurrent Medications & Supplements:None Preventative Care Status-Vaccination status - TBC-Parasite control: UTD Diet & Lifestyle-Brand/type of food: Kibble and steak at night Other animals in household: yes his brother wolfie Travel history:NoneExposure risks (ticks, beaches, bushland etc): minimal Previous reactions to vaccines or medications: no Physical Examination-Weight: 4.3kg -Body Condition Score (1–9): 3-Temperature: Not taken -Heart rate: wnl -Respiratory rate: wnl -Mucous membranes / CRT: pink, <1.5s-Hydration status: normal Full Clinical Examination-General appearance: good -QAR-Skin & coat - mild epidermal collarettes present, on AB currently for it -Ears - improving on dermotic -Eyes: wnl -Oral cavity & dentition: wnl -Lymph nodes: wnl -Cardiovascular: wnl -Pulse quality: good -Respiratory: wnl -Abdominal palpation-Pain? no but spinal pain suspected - mid lumbar region  -Organomegaly? no -Masses? no -Musculoskeletal - good ROM of both hips and knees. Mild laxity noted right stifle, less so in left, no luxating patellas present. Right hind leg is being held rotated inward? Pain or neuro? -Gait: tender on hind legs, not skipping-Joint pain: mid lumbar region -Muscle mass: okay-Neurological (if indicated) - normal CP present-Mentation: QAR-Proprioception: good -Cranial nerves- wnl -Urogenital (if indicated)- wnl?Assessment-Problem list Painful lumbar region -Most likely diagnosisMM pain, underlying Lumbar pathology - IVDD? -DifferentialsAbd pain presenting as back pain -SeverityModerateTreatment Plan- Rest and Pain control with anti-inflammatories- Inj meloxicam 0.17ml SC - to cont on oral meloxicam (o has already) - Add in GABA 25mg BID to start to try calm him down and ensure he relaxes. - INI consider radiographs on friday at PAHClient Communication-Risks discussed-Side effects explainedPrognosis discussedFollow-Up PlanRecheck date: 11/03/26, sooner iniWhen to return urgently: if loss of CP or deterioration occurs     Vital Signs    Weight: 4.3;