C10002918 / invoice 10000

NOTES: Vet: VAB 
VL:

Is the client using GapOnly today? YES/NO

HISTORY
Specific owner concerns: lump on tummy near spey incision 
Diet: 
Appetite: okay 
Weight changes (compared to our recorded weights): maintaining 
Water intake: good 
Vomiting/diarrhoea? no 
Urinating normally? yes 
Abnormal breathing, coughing, respiratory signs: no 
Signs of arthritis/reduced exercise ability? no 
Any lameness? no 
Skin concerns (including eyes, ears): lump over spey incision site (speyed Oct 2025), noticed yesterday, grew fast, AREC last night - antibiotics and painkillers, reaction from dissolving stitches, licking at it, little lethargic/not herself 
New lumps (include timeframe, changes, bleeding etc): no 
Current medications: AREC last night gave antibiotics and painkillers (Meloxicam + Juroclav) 


NURSE TO CHECK
Confirm owners details on file
Microchip on system – YES 
Check microchip on NSW database YES/NO
Is the pet due for anything else? (check reminders, vaccination, heartworm inj, arthritis etc) YES/NO 
Flea and tick prevention – Nexgard Spectra UTD
Heartworm prevention –  ''
Intestinal worming prevention – ''
Do they need more medication?
Have you heard there is now a once a year injection for flea's and ticks? (Dogs only delete if  cat) not discussed 

EXAMINATION
Demeanour: BAR 
Eyes: NSF. Clear.
Ears: NSF. Canals normal, no signs discharge
Nose: NSF. No discharge
Mouth: NSF 
MM: p/m 
CRT: <2s 
Dental score:  0.5/4
Lymph nodes: NSF
Chest auscultation: NSF. No murmur detected. Lungs clear in all fields
Femoral PR and pulse quality: strong and synchronous with HR 
Respiratory effort: none 
Abdo palpation: NSF
Skin and coat: NSF
Musculoskeletal: NSF
Temperature: not obtained 
BCS:  2.5/5
Neurological: ambulatory and mentally appropriate, full exam deferred
Behavioural notes: good for exam 

TREATMENT
Continue with Meloxicam + Juroclav that AREC dispensed (5-7days)
Recheck when those meds end 
Keep quiet/indoor, keep wound clean/dry 
E-collar 24/7 

RECHECK required? YES 5-7d 
Booked in? YES/NO

Dental estimate – NO
Vaccines: No
Nail clip – NO
Anal glands – NO
Ear clean – NO
Bum or face trim – NO

NOTES: Vet:: VLF
VL:

Reason for presentation: Eyes

Is the client using GapOnly today? YES/NO

HISTORY
Describe what is happening: Was playing with a ball yesterday and got hit in the eye, was crying for a bit after it happened. L eye a bit swollen and squinting. A bit red and sore 
One or both eyes affected: L eye 
Has it happened before: no 
If so, when/what happened/did it resolve on its own or with medication: no 
Any ongoing condition diagnosed (eg. Dry eye, entropion): no 
Squinting/rubbing at eyes: squinting 
Any discharge, if so what colour: no 
Is the skin/ears ok? yes 
Any changes with pupils: no 
Any vision loss?  no 

Specific owner concerns:
Diet: biscuits
Appetite: good 
Weight changes (compared to our recorded weights):
Water intake: normal 
Vomiting/diarrhoea? no 
Urinating normally? normal 
Abnormal breathing, coughing, respiratory signs: no 
Signs of arthritis/reduced exercise ability? no 
Any lameness?
New lumps (include timeframe, changes, bleeding etc):
Current medications: no 

NURSE TO CHECK
Confirm owners details on file
Microchip on system – YES/ADDED
Check microchip on NSW database YES/NO
Is the pet due for anything else? (check reminders, vaccination, heartworm inj, arthritis etc) YES/NO 
Flea and tick prevention – UTD but unsure of product 
Heartworm prevention –  ""
Intestinal worming prevention – "" 
Do they need more medication?
Have you heard there is now a once a year injection for flea's and ticks? (Dogs only delete if  cat)

EXAMINATION
Left eye: L eye blepharospasm, marked conjunctival inflammation, scleral injection 
Right eye: nsf 
Pupils: Intact
PLR/Menace: Intact 

Demeanour:
Ears: NSF. Canals normal, no signs discharge
Nose: NSF. No discharge
Mouth: nsf
MM: pink, moist
CRT: <2
Dental score:  1/4
Lymph nodes: NSF
Chest auscultation: NSF. No murmur detected. Lungs clear in all fields
HR: 100bpm 
Femoral PR and pulse quality: s/s 
RR: 40bpm 
Respiratory effort:
Abdo palpation: NSF
Skin and coat: NSF
Musculoskeletal: NSF
Temperature: DNE
BCS 3/5
Neurological: ambulatory and mentally appropriate, full exam deferred
Behavioural notes: anxious but lovely 

PROBLEM LIST

RECOMMENDED DIAGNOSTICS
Fluroscein stain - nil uptake in L eye 
STT - did not perform 
IOP - 
L eye 18
R eye 16

TREATMENT PLAN
Start meloxicam SID then recheck in 7d 

RECHECK required? YES
Booked in? NO


Dental estimate – NO
Booster vaccine due – NO
Nail clip – NO
Anal glands – NO
Ear clean – NO
Bum or face trim – NO

NOTES: NURSE: njc

no answer left message 

Reason for Phone Back: post de sexing yesterday 

HISTORY
Is the issue resolved - 
Any other concerns - 
Any medications remaining - 
EDDU – 
Vomiting or diarrhoea - 

Follow up required - YES/NO
- Recheck appt made
- Follow up phone call made
- No further follow up required