C10006333 / invoice 10000

Reason: Sore On Back Hip - TMDiet: Preventative healthcare:Vacc:HWP:IW:Flea/tick:HISTORY:O's presenting complaint(s): Examine:PHYSICAL EXAMINATION: BCS: ## / 9MCS: normal muscle mass #Mentation: alert and responsiveEYES: NAD - clear, no noted discharge #EARS: NAD - clear, no discharge, odour, erythema#NOSE: NAD - clear, no discharge, symmetrical, no lesions #ORAL: NAD - normal pink and moist mm, normal CRT, healthy teeth & gums#CARDIOVASCULAR - NAD - no murmur or arrhythmia auscultated, pulse pressures normal and synchronous#RESPIRATORY: NAD - thoracic auscultation clear sounds bilaterally, respiratory effort normal#ABDOMINAL: NAD - soft pliable, no detectable pain or palpable abnormalities#NEURO: NAD - neurologically no significant findings, no cranial nerve or proprioceptive deficits/gait#MUSCULOSKELETAL: NAD - ambulating with normal gait & posture, no pain on palpation of joints, appropriate ROM#RECTAL: not performed#REPRODUCTIVE: externally normal #INTEGUMENT: NAD - clear coat and skin #LYMPH NODES: NAD - peripheral nodes palpate normal #Assessment:Plan:--- 09/03/2026 18:10:36 CM:Worming - Skipped on 07/09/2025Canine Cough Vaccine - Skipped on 25/02/2026Verified: NoSubjective:Diet: puppy food for optimal nutrients, still gaining weight, described as a little tubbyRecent changes to diet: decreased appetite recently, hasn't had breakfast, won't touch food but may eat when homePreventative healthcare:Vacc: vaccination delayed until after lactationHWP: IW: Milbemax mentioned as acceptableFlea/tick: Bravecto mentioned as acceptableHISTORY:O's presenting complaint/s: skin sore with discharge, concern about infection- Skin lesion present for approximately 2.5 weeks- Lesion described as inflamed with moist discharge- Possible insect bite or scrape injury- Patient is pregnantAppetite: decreased recently, not eating breakfastThirst: NormalVomiting: NilDiarrhoea: NilAccess to chemicals or toxins: Nil knownAccess to rodenticides: Nil knownCurrent medications: NilPrevious medical history: Nil relevantPatient is pregnant, male dog present but not the fatherExamine:PHYSICAL EXAMINATION:Mentation: alert and responsiveEYES: NAD - clear, no noted dischargeEARS: NAD - clear, no discharge, odour, erythemaNOSE: NAD - clear, no discharge, symmetrical, no lesionsORAL: NAD - normal pink and moist mm, normal CRT, healthy teeth & gumsCARDIOVASCULAR - NAD - no murmur or arrhythmia auscultated, pulse pressures normal and synchronousRESPIRATORY: NAD - thoracic auscultation clear sounds bilaterally, respiratory effort normalABDOMINAL: NAD - soft pliable, no detectable pain or palpable abnormalitiesNEURO: NAD - neurologically no significant findings, no cranial nerve or proprioceptive deficits/gaitMUSCULOSKELETAL: NAD - ambulating with normal gait & posture, no pain on palpation of joints, appropriate ROMRECTAL: not performedREPRODUCTIVE: externally normalINTEGUMENT: inflamed skin lesion with moist dischargeLYMPH NODES: NAD - peripheral nodes palpate normalAssessment:Problem List:- Inflamed skin lesion with discharge, possible insect bite or traumatic injury- Decreased appetite in pregnant patientTreatment:Plan:- Clean lesion with diluted Betadine solution BID- Apply Pinetarsol cream (chlorhexidine-based antiseptic) after cleaning- Continue treatment for one week- Monitor for improvement- Return if condition worsens or patient continues licking area- Vaccination to be delayed until after lactation- Milbemax worming acceptable during pregnancy- Bravecto flea/tick prevention acceptable during pregnancy    Vital Signs