C10007891 / invoice 10000

HISTORY- A few days agoafter visitng a friend, Agitated behaviour, unable to settle but has since resolved- Licking one of her legs- Coughed twice, about 2 weeks ago but otherwise coughing resolved- No current ear issuesEXAMEars: No inflammation, no redness, allows handlingMouth: Minimal tartar, more on the RHL side, had 108 removed and now likely not chewing as much on that sideHeart: Very mild LHS murmurAnal glands: Not full, no impaction notedGeneral: No signs of irritation between digits, overall condition goodDIAGNOSIS- Possible pain response or allergic reaction causing agitation and discomfort?- Resolved gastrointestinal upset?- Very mild heart murmur, unrelated to current symptomsPLAN- Monitor stool consistency for changes or signs of gastrointestinal upset- Daily teeth brushing, focus on RHL side- Consider dental health maintenance to prevent periodontal disease progression- Recheck ears and overall health at next vaccination due in May 22- Keep an eye on cough, though it seems to have resolved and is not related to heart disease- Advised cardiac U/S

**HISTORY/REASON FOR VISITCoughing for approximately 1 month, SID or BID, sounds like a hoarse coughSeems a bit tired and lethargic for the last few days, less energy than usualLast night stood and whimpered at owner around 5pm, went to bed earlyStill eating well and wants to play ballAlways on lead, walks daily, has contact with other dogs PHYSICAL EXAM:Demeanour - BAR, brightBCS - 2.5-3/5Cardiovascular - Very mild heart murmur LHL side, mitral valve region, difficult to hear, approximately grade 2/6, heard intermittentlyRespiratory - RR: lung sounds clearMM colour/CRT - pink, moist, CRT <2Eyes - clear, minimal dischargeEars - no erythema or dischargeNose and Throat - NSFOral Assessment - NSFMusculoskeletal - NSFIntegument - healthy coat, no lesionsAbdominal palpation - comfortable with deep palpation, no abnormal structures feltRectal - not assessedTemperature - 38.2PROBLEM LIST:Coughing - canine cough, early airway inflammation, allergies, less likely related to heart murmur at this stageMild heart murmur LHL - mitral valve insufficiency/regurgitation, early degenerative valve diseaseLethargy - mild, likely related to coughing/airway inflammationDIAGNOSTICS:None performed todayTREATMENT:MeloxicamPLAN / DISCUSSION WITH OWNER:Heart murmur newly detected, very mild grade 1-2/6 on LHL side, likely mitral valveUnlikely to be causing cough at this stage - murmur too mild, lung sounds clear, no signs of CHFCough more likely canine cough, airway inflammation, or allergies given duration and naturePrescribed meloxicam 12.5mg (1/2 tablet) PO SID for several days to reduce airway inflammationGive with or after food to reduce GI upsetIf cough worsens, persists, or dog becomes more lethargic, recommend chest radiographsTry to get video of cough if possible to help characterize itEcho may be considered in future to baseline heart changes but not urgent at this stageMonitor resting respiratory rate at homeRecheck if any concerns or cough not improving

Nurse Laura: Recovery: Slept yesterday afternoonWounds/dressings: How are any wounds/dressing/bandages looking?Eating/drinking: Eating and drinkingToileting: Have they toileted?Medications: If any medications, have they managed to give them/reminder to give?Revisits: Recheck in 1 monthOther: