C10002950 / invoice 10000

Annual Vac + Proheart


Verified: NO

HISTORY
Presenting for: Daisy, a 3-year-old female Kelpie from rescue, presented for ProHeart injection.

Historical Conditions:
- Hip dysplasia diagnosed at JCU
- Previous arthritis injections approximately 12 months ago with good response
- Psychosomatic reaction when touching back end area

Diet:
- Alternates between homemade vegetable bean stew with brown rice, stock, lentils, green split peas and various vegetables, and dry kibble
- Receives oily fish such as mackerel
- Eating well, no appetite concerns

Current Meds:
- 4Cyte daily for joints
- Kennel cough vaccination due 11/6 but not routinely kennelled
- Lepto vaccination current (done December, Christmas Eve)

Lifestyle Risk Factors:
- Lives on property with 4 dogs total
- Does not attend dog parks or interact with other dogs outside household
- Dogs are house-sat when owners travel, not kennelled
- Minimal exposure to other dogs

EXAM
Mentation: BAR
Wt: 21.8 kg
BCS: Slightly overweight, would benefit from more defined waist tuck
Behavioural: Very good patient, cooperative during examination and nail trimming (noted as previously difficult for nail trims), accepted treats
Oral: Nice teeth, loves bones
Integumentary: Lovely coat condition, nails were overgrown but successfully trimmed
Musculoskeletal: Tight in hips, does not like hip extension, reduced normal range of motion compared to normal dog, jumps in and out of car without difficulty, able to leap onto back of ute

ASSESSMENT
Hip dysplasia - Previously diagnosed, currently managing well at home with jumping and normal activity levels. Reduced range of motion on examination but functionally sound.
Weight management - Slightly overweight which may contribute additional pressure on hip joints.

PLAN
Medications/Treatments:
- ProHeart injection administered today
- Arthritis injection course commenced today (4 injections total over 4 weeks)
- Next 2 arthritis injections scheduled with nurse at weekly intervals
- Final arthritis injection to be scheduled with veterinarian
- All arthritis injections pre-billed today

Additional Discussion:
- Kennel cough vaccination declined as patient has minimal exposure to other dogs and lives on property
- Weight loss recommended to reduce pressure on hip joints
- Monitor for signs of hip discomfort such as morning stiffness or reluctance to jump in car
- Can restart arthritis injection course in future if signs of discomfort develop

Lepto 

History: owner has no concerns to report is going well, is on 4 cyte daily for underlying hip dysplasia and owner thinks is going well, did have course of zydax injections but going to leave these for later on when has any problems with hips and continue 4cyte for now

Examine:
BAR
HR 128bpm, no murmur auscultated
RR normal rate/effort, lung fields sound clear
Crt <2secs, MM pink
Eyes/ears/nose/oral NAD
Abdomen NAD on palpation
Integument NAD

Treatment:
Lepto given
Annual booster required.

Annual Vaccinations - Adult Dog

Vaccination - Adult Canine Vaccination

HISTORY:
Been well at home. EDDU normally.
O has (no) concerns.


EXAMINATION:
Mentation: (BAR: Jumps around when ever touch back end. o note does the same at home. not painful but response from when they rescued her)
Ears: (NAD)
Eyes: (NAD)
Nose: (Symmetrical, nil discharge, healthy membranes, nil discolouration)
Oral Cavity and Dentition: (NAD)
Peripheral LNs: (WNL)
CVS: HR (WNL) bpm. Normal heart sounds and rhythm. Normal pulses with no deficits. 
MMs pink, moist. CRT <2 secs.
Resp: RR (WNL). Normal resp rate and effort. Normal lung sounds auscultated. No cough elicited on tracheal palpation.
Abdomen: (NAD on palpation, nil distension)
Musculoskeletal: (NAD on spinal musculature palpation, nil mm atrophy, normal ROM at all 4 limbs).
Gait: (NAD)
Integument: (NAD)

ASSESSMENT: 
FFV

TREATMENT:
Vaccination: (C3 + KC) 

PLAN:
(Return in DEC for lepto. try and come 1mth late for proheart to then do both proheart and KC at same time )