C10004472 / invoice 20000

    Vital Signs    

Reason: Seen Through ECCAppointment Notes: wants UVTHS to be new GP.16.2.26 SMFRecord Entered by: Vet student Tiffany Son Record Checked by: BIOSECURITY STATUS:  PRESENTING COMPLAINT: 12YO FS Jack Russell Terrier Frankie presenting for general health check and vaccination.HISTORY: SPECIFIC HISTORY:Previously visit ECC Dec 2025 for acute pancreatitis - was hospitalised + supp care + NGT feeding; Jan 2026 for acute V+ and exercise intolerance - tx with maropitant + pimobendan (as grade IV/VI heart murmur).Wanted to swap over from Drummoyne vet to UVTHS for primary vet.Has been going well since Jan 2026, occasional V+ that had self-resolved. Owner reports Frankie to still cough intermittently but not as much as she used to (owner not concerned). Occasional breathing up during rest which has been abnormal.Owner wanted to address the following today:- Booking in for echo and dental tx- Supplementation for geriatric care: currently on 4cyte but wanted to know what other supplements could be given as sometimes noticed a bit of stiffness. No lameness or limping observed by the owners- Has been drinking excessively for a few months (before Dec visit). Normal urination (no increased frequency or amount with the increased drinking)- Has been licking RF paw. No pain associated and still weight bearing. Not licking or scratching other parts of the body.- Warts popping up all over the body- Wanted to assess sight and hearing as owner suspects they may not be present.- Vaccination 3 months overdue, need to update (owner unsure what vaccinations Frankie received at Drummoyne vet)  NON-SPECIFIC HISTORY: LIFESTYLE: Indoor/Outdoor/Indoor & Outdoor: Mostly indoors, unsupervised access to yardsBEHAVIOUR ISSUES: At Vet/At Home Has tried nipping other dogs OTHER PETS: None DIET: Kibble breakfast and lunch, BBQ steak and veggies at nightCURRENT OR RECENT MEDICATIONS:- pimobendan 3/4 tab of 2.5mg PO BID- 4cyte SID APPETITE,THIRST,COUGHING ETC: EDDU all normal and consistent. No sneezing, vomiting or diarrhoea. Sometimes runny poo but one-offs (may pick up stuff from the ground). VACCINATION: - Got a reminder from Drummoyne vet the other day that Frankie was 3 months overdue for vaccination and health check- owner wanted to update todayPARASITE PREVENTION (incl. Compliance): Fleamail --> receive Simparica trio and another all wormer (not sure which is which but they get one tablet delivered every month and 2 tablets every 3 monthly) PHYSICAL EXAMINATION:Student tried examining, was a friendly dog but tried to nip during dental exam. Muzzled with owner holding and treats through the muzzle for the rest of exam, relatively well-tolerated.WEIGHT: 7.1kgFAS SCORE  /5: 2/5MENTATION: BARHR:                                                     	---PULSE QUALITY:                            	strong, synchronousRR:                                                     	----TEMPERATURE:            	                ---INTEGUMENT:                              	Marked salivary staining and alopecia on dorsal and palmar surface of RF paw. Small 2mm nodule on LH limb (dorsal surface), owner reported more and possible bigger nodules but could not find during the consult. Otherwise, healthy coat and skin. CIRCULATORY:              	            MM pink and moist, CRT <2sec, grade IV/VI heart murmur, femoral pulses strong and synchronous. RESPIRATORY:               	            No wheezing or crackles, normal bronchovesicular sounds bilaterally.DIGESTIVE:                                     	No palpable abnormalities on superficial or deep palpation of the abdomen. Comfortable on palpation.Oral Cavity:                 	                        Mild-moderate plaque with minimal gingivitisGENITOURINARY:                        	No discharges from vulva. Desexed animal. Bladder small and comfortable, kidney palpation unremarkable.MUSCULOSKELETAL:                  	No lameness or ataxia appreciated. Full MSK exam not performed. NEURAL:                                          	Normal, appropriate mentation, full neuro exam not performed. LYMPH NODES:             	            Submandibular, prescapular, inguinal and popliteal lymph nodes symmetrical and normal size and consistencyEYES:                                                 	Both visual, bilateral nuclear sclerosis, no blepharospasm or epiphora EARS:                                                	Responds to auditory stimulus, ears free of discharge or odour. BODY CONDITION SCORE:        	6/9 IN-HOUSE DIAGNOSTIC TESTS:- sticky tape prep of RF paw: some cocci++ASSESSMENT:Problem list:1. Vaccination not up to date - updating some today2. RF paw pruritus - dermatitis (allergy, insect bite hypersensitivity, atopy - although not anywhere else in the body) ddx behavioural 3. Reported polydipsia - endocrine dz (DM, hyperA, hypoA, hyperT), renal dz, perceived polydipsia, recent hot weather (transient)4. Nodules (warts), sight (bilateral nuclear sclerosis), hearing - most likely age-relatedInclude your clinical impression of the animal: Frankie presented bright, alert and responsive. Her physical examination revealed common age-related changes including bilateral nuclear sclerosis, mild stiffness of limbs, presumed benign cysts (advised owner would require FNA or excisional biopsy for definitive diagnosis). Her vision is still present and assessment of hearing was difficult as the patient was stressed. She has moderate plaque build up but dental treatment is not urgent currently. The patient's heart murmur in conjunction with occasional breathing up and cough warrants further investigation via echocardiogram with a specialist. A sticky tape prep of RF paw revealed moderate cocci, however environmental contamination cannot be ruled out. Conservative management of the RF paw for now with malaseb shampoo but may require medication if not improved. Polydipsia may indicate endocrine disease, but her biochemistry from Dec 2025 was unremarkable and no other clinical signs were present. Otherwise healthy pet, fit for vaccination. TREATMENT:Given Nobivac FlexDHP and Lepto 2 today PLAN (incl. alternative options):1. Discussed with owner what to do with the vax (attempted to call Drummoyne vet but closed today): 1) we contact the previous vet and they can come back for appropriate vaccination, 2) start C3 and Lepto, get hx and if require lepto booster and/or KC we can contact them (as owner reported minimal contact with other dogs). Owner opted for (2), we will request for hx from Drummoyne vet, and contact owner with info.2. Informed owner about echocardiogram (only Tuesdays), estimate provided. Echo will provide us more about medications and anaesthetic risks for the dental procedure (dental not urgent and can wait till after echo, estimate will still be sent to owners for future reference).3. Supplementation: can continue 4cyte. Can add fish oil (but further info about dosage after echo as fish oil may also be recommended by cardiac specialist). Briefly discussed Beransa inj (may not be necessary now as not showing obvious signs of arthritis but considertaion for future).4. Monitor fluid intake (measure water bowl) as may still be within normal range. If not further investigation warranted.5. Nodules: monitor for now, workup if rapid increase in size or signs of ulceration or inflammation6. Paw: malaseb shampoo leave on for 10mins 2-3x a week and decrease slowly over timeASA Classification (if applicable):  VACCINATION DETAILS:Vaccination injection site: mid back with lepto 2Type of vaccination given: Nobivac Flex DHPBrand of vaccination: MSDBatch number: 2519605Expiry date of vaccination: 07-2027Vaccination injection site: mid back with DHPType of vaccination given: Nobivac Lepto 2Brand of vaccination: MSDBatch number: A003A02Expiry date of vaccine: 10-2026    Vital Signs    Weight: 7.1;       MMColour: Pink;       BodyScore: 6;       DentalGrade: 2;       CRT: < 1 sec;