C10005923 / invoice 10000

Reason: Sore Back Left Leg - CNAppointment Notes: Advised that they may need to come back for xraysOverdue remindersHistory:Yesterday went for a walk and was finePlayed with some toys in the house Then suddenly non weight bearing LHStill eating and drinking fineWas taken to aES overnight, has nurse triage but declined vet consult Putting less weight on it todayToday non-weight bearing LH Examine:COAT/SKIN: no abnormality detectedEYES/EARS: no abnormality detected, ears and eyes clean and clearMOUTH/TEETH: Oral exam normal, no mouth pain, dental score:1HEART: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousLUNGS: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeABDOMEN/DIGESTIVE/URINARY: no abnormality on palpationCNS/MUSCULOSKELETAL: normal palpebrals and menace bilaterally; non weight bearing LH, yelping when examining the left stifle, lumbar spine NAD, no palpable neck pain, spine, limb, joint painPeripheral Lymph Nodes: no abnormality on palpationWEIGHT/DIET: Body Condition Score:REPRODUCTIVE: entire Other:Worming/Heartworm/Flea control status:UTDNutrition:Laboratory:  Recom bloods Differential Diagnosis:Soft tissue injury vs early partial CCL vs MPL vs unilateral lumbar spine nerve rootPlan:Left stifle tibia has mild cranial translation compared to right but minimal effusion Mild positive TT left stifleNo injuries/wounds palpated Lumbar spine WNLHips WNLOnto metacam and rest for 7 days then reassessPet Primary Diagnosis/Suspected Diagnosis/Location:Acutely lame left hind suspect cruciate tear vs patella Suspect cause:traumatic Any other conditions being treated (if any):nil Known health concerns:nilDate of first clinical signs (if known):8/3/26To be filled in prior to submitting claimAdditional notes can be added later    Vital Signs    Weight: 7.4;       

    Vital Signs    

Reason: Vaccination &HWAppointment Notes: Overdue remindersHistory:Been well, no health concerns. EDDU normal. Have started feeding kibble as well as wet food. Eats about 6:30 or 7, cooked dog mince. Then kibble in afternoon around lunch time. Gets a walk in the afternoon, then gets some dinner about 112pm. Cooked chicken with veggies. Scratching at ears a little. A couple of belly spots after recent grooming. Possibly some dental issues. Mobility ok at this stage. Very occasional - LF leg was stiff.Examine:COAT/SKIN: no abnormality detectedEYES/EARS: no abnormality detected, ears and eyes clean and clearMOUTH/TEETH: Oral exam normal, no mouth pain, dental score: c2g1 no obvious extractions, although minor gingival recession around 407HEART: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronous LUNGS: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeABDOMEN/DIGESTIVE/URINARY: no abnormality on palpationCNS/MUSCULOSKELETAL: normal palpebrals and menace bilaterally; ambulating normally, no palpable neck pain, spine, limb, joint painPeripheral Lymph Nodes: no abnormality on palpationWEIGHT/DIET: Body Condition Score: 6/9REPRODUCTIVE: no significant abnormalities, entireOther:Worming/Heartworm/Flea control status: utdNutrition:Rectal: WNLLaboratory:  Ear swabs: occaisonal malassezia both ears (0-1 PER HPF)Plan:: Recommend dental. No obvious extractions although discussed the possibility of finding one or more on the day after xrays and examination. Ears not worth medicating at current condition, although recommended recheck if shaking/scracthing worsens.Assessment:Fit for vaccinationTreatment:Protech C4 SQ + Bronchishield I OralAnnual Heartworm injection 0.4 ml SC Heartworm injection given    Vital Signs