C10009221 / invoice 10000

Appointment Notes: Unsettled last night, possibly sore?HISTORY:Doing well: Eating, drinking and toileting normallyCurrent Medications: None including panadolMedical conditions: None Vomiting or diarrhoea: NoAny Concerns: None Diet: Appetite and thirst: Normal ate dinner around 7 last night poached chicken, and a rawhide bone as a treat and was eating it and then started wandering and following OFlea/tick: Worming: Primary complaint/relevant information:  Last thurs visit to rehab, urinating and drinking inside, not playing in water so he didm't have a fever last nightpanting lots with stress from vet visit, wandering all night, he was given some sedatoin around 930, this started 730, he settled around 430 this am and has started again and had another sedative at 7am, would scratch h at the door but not go outseemed distressed when wandering but not as much this am, no vagueness or staring, tail was down last night and wouldn't sit still for long, drink a  lot last nightDisease onset Progression and duration: Current Medications: None  EXAMINATION: Demeanour: BAR MM: Pink, moist, CRT <2 Eyes: Clean and clear, normal eyelids, no erythema or discharge Ears: Minimal debris, no inflammation or odour,  no bulging inner earLymph nodes: Peripheral lymph nodes palpably normal Oral: No oral lesions or abnormalities detectedTeeth: Dental grade 1/4, normal occlusion. COHAT Level Estimated: (A, Cardiovascular: Normal heart sounds, no murmurs or arrhythmias detected, femoral pulses synchronous and normodynamic Respiratory: No nasal discharge, normal bronchovesicular lung sounds in all 4 quadrants, one coughing seen on trach palp, noi crackles and no resp distressAbdomen: Soft and comfortable on palpation, no masses palpated, bladder unremarkable, very difficult to get any defintionMSK: Normal gait no lameness. Normal ROM with no pain of all limbs. No pain on DV palpation of spine Integument: Coat is soft and clean, no ectoparasites detected, no obvious skin lesions or masses, skin around eyes is scabbed with tears and shaved it off and the skin under is pink from the constant wetnessNeurological: Normal mentation, no ataxia or CP deficits observed. Full exam not performed Reproductive/Urogenital: External genitalia normal in appearance Rectal: Not performed PROBLEM LIST: pacing, ? painDIAGNOSTICS: advised bloods to assess kidneys and also for Cushings, O not want at this timeASSESSMENT/DDX: can't find a repeatable pain focus but has had gaba since last night x 2, fair to assume he has pain in his hips as before but gaba has masked itPLAN: trial metacamMEDICATION: metacam oid 3dCLIENT COMMUNICATION: N/A TREATMENT: ini then need to contact us, can consider paracetamol, ini during today the r/v this arvo or call us and can trial paracetamol on topHandouts given: Health report / Dental / Arthritis / Other (Name)Estimate provided (Y/N or NA)    Vital Signs    Weight: 10.6;       MMColour: Pink;       HeartRate: 112;       Temperature: 39;       BodyScore: 7;       CRT: 1-2;