C10009308 / invoice 10000

Reason: Sore NeckAppointment Notes: Special payment terms exist, Overdue remindersPresented and seen by Dr   Corne Loots on 10/3/26 Regular Vet:Greencross WyomingPresenting Problem:Neck painHistory:Was at the groomer and jumped off a ledge and yelped. He was immediately uncomfortable and owner has given him 100mg gabapentin,Dental in May 25, hip toggle Sept 25. Any current medications:NoneAny access to potential toxins?:NoE/D/U/D:Fussy eater, but no abnormalities reportedPreventatives up to date? YesExamination Findings:General demeanour:QARTemperature:WNLsCardiovascular:Regular, no murmur, pulses strongRespiratory:Normal effort and rate, lung sounds clearOral exam:Grade 2 periodontal diseaseAbdomen:Comfortable , no massesPeripheral LNs:NADEyes/Ears:NADIntegument:Healthy, some small warts, and some small signs of close clippingMusculoskeletal:Was initially keeping his neck turned to the left. Crying when moving neck to the right (can but prefers not to). No lameness observed in any of his limbs.Good muscle mass and toneGait:AmbulatoryNeurological:No Apparent abnormalities, normal proprioception in all 4 limbs.Rectal exam:Not performedUrogenital:NADBody Condition Score:IdealInitial Assessment:Neck pain-, trauma, soft tissue, OA, IVDD, otherClient Communication:Discussed possible causes and follow up diagnostics incl CT. Given how the symptoms started trauma, is likely the cause. Owner declined NDSAID bloods for now.Treatment:0.2mg/kg methadone im and 0.5mg/kg ketamine im Paracetamol 60mg every 8-12 hoursGabapentin 100mg every 8-12 hoursPlan:Keep rested, crated and take out for toilet breaks. Revisit if pain does not subside. Owner has Meloxicam and Temvet at home previously prescribed by RV    Vital Signs    Weight: 5.4;       MMColour: pink;       HeartRate: 104;       BodyScore: 4.5;       DentalGrade: 2;       RespirationRate: 28;       PainScore: 1/2;       CRT: 1s;