C10005913 / invoice 10000

HISTORY: Presenting Complaint:
Regular vet:

History:

Appetite:
Water intake:
Urination:
Faeces:
Energy levels:
Coughing or sneezing: 
Vomiting: 
Diet:
Parasite Control:
Vaccination status:
Current Medications:

Observation:
EXAMINATION
Demeanour: 
BCS: /9
Integument: 
Eyes:
Ears: 
Nose: 
Mouth:-
CRT:           
MM: 
Dental disease: Grade - /4
HR:   BPM,    Rhythm:
RR:   BPM,    Effort:
Temp:   C
Peripheral LN's: 
Abdomen: 
Musculoskeletal: 
Neurological: 
Urogenital:
Rectal:

Assessment:

Client Communication:

Plan:
WEIGHT: 40.10

HISTORY: REASON – In for annual health check and vaccination

HISTORY - Doing well. Is getting cytopoint as needed but appears well for now. 
Has lost about 10 kg body weight as O been good on food portioning, has minimized giving biscuits.
Has lost weight as normally lives with parents when owner away FIFO - parents have been away on holidays so not staying with them so only getting his portioned dog food - no treats, no leftovers, no toasted sandwiches etc
also starting to go for short walks which wasn't before
hasn't been unwell at all - looks good

Appetite: wnl
Water intake: wnl 
Urination: wnl
Faeces: wnl
Energy levels: wnl
Coughing or sneezing: nil
Vomiting: nil 
Diet: SPD dog roll SID 
Parasite Control: due - not
Last Vaccination: due 
Current Medications: nil 

EXAMINATION
Demeanour: BAR, lovely boy
BCS: 5/9
Integument: 
Eyes: NAD
Ears: NAD
Nose: NAD
Mouth: NAD 
CRT:    1 sec       
MM: pink 
Dental disease: Grade - 0/4
HR: 130  BPM,    Rhythm: no murmur 
RR:   BPM,    Effort: panting 
Temp:   not taken 
Peripheral LN's: 
Abdomen: soft
Musculoskeletal: ambulates normally on all 4 legs
Neurological: nad, full exam not performed
Urogenital: nad 
Rectal: NAD

ASSESSMENT:
Fit for vaccination 

CLIENT COMMUNICATION:
Weight loss has been spot on and very beneficial for Caiden. 

TREATMENT:
Pi2 injection SC Batch: 5264017 Exp: 06.01.2027
BB injection SC Batch: 15607 Exp: 10.26
Parasite control: overdue

PLAN: C5 in 12 months 

ESTIMATES:

REVISIT:

ADDITIONAL DISCUSSED:
1, Dental COHAT: YES/NO
2, Desexing: YES/NO/Not applicable
3, Insurance YES/NO
4. Vaccination Reaction: YES/NO
5. Given relevant handouts and pet report card YES/NO
6. Booked for next vaccination  (            )    in 12 months time  YES/NO
WEIGHT: 38.00

HISTORY: REASON – vac and cytopoint

HISTORY - 
Walks: was going around the block, but have stopped because of limping. Limping improved a bit. 
Not favouring a particular leg, more hobbling. 
This was about 6 weeks ago. 

2x 30mg vial given last year, this helps his skin
Have used malaseb in the past

Appetite: good
Water intake: no change
Urination: no change
Faeces: no diarrhoea
Energy levels: ok
Coughing or sneezing: 
Vomiting:  none
Diet: 3/4 cup of dry food in am, not always eating all of this. eating it over the day. 
SPC 300g of wet food
Parents give him extra treats
Parasite Control:
Vaccination status: had c5 last year. due KC
Current Medications:

EXAMINATION
Demeanour: BAR
BCS: 8/9
Integument: erythema, staining of fur and moisture in front paws. Small amount hind paws
Eyes- Clean, no discharge
Ears: Clean, no discharge
Nose: Clear, no discharge
Mouth: CRT <2 secs, MM: Pink and moist
Dental disease: Grade - 1/4
HR: 140 BPM, normal rhythm. no murmur detected
RR: panting normal bronchovesicular sounds bilaterally.
Temp: not taken
Peripheral LN's: 
Abdomen: soft and comfortable for palpation, no evidence of organomegaly
Musculoskeletal: shuffling gait, short stepping behind
reduced muscle mass hind legs compared to forelimbs. 
bilateral stifle thickening and crepitus. pulling away on stifle extension
ok with hip extension
Neurological: No neurological abnormality noted

ASSESSMENT:
allergic skin disease
over weight  - but has lost 3 kg in 1 year
DJD/curictae disease

CLIENT COMMUNICATION:
Keeping pain under control will allow for more walking which will help weight  loss
Discussed NSAIDs vs beransa. O happy to start with beransa for now

TREATMENT:
Cytopoint 2 x 30mg vial as previously used 748072 exp 02.2026 (left shoulder)
beransa 30mg - 733571 exp 10.25 (right shoulder)

Bb oral 5245038a exp 22.8.25
pi2 5264014 exp 14.6.26

PLAN:
revisit 4 weeks for next beransa
slowly increase walking again
WEIGHT: 47.00