C10010521 / invoice 10000

Hx
Presented for not himself
didn't run to O when she got home, not jumping up like normal, only ate half breakfast
no V+ or D+ noted but didn't see any defecation when checking - usually regular
on royal canine, over long weekend had to have super coat for a few meals back on RC today 
not one to eat random things 

Exam
BAR
HR WNL
RR WNL
MM pink moist CRT<1
Abdomen moderately painful mid to upper abdo no obvious lumps or bumps 
Ears, eyes, nose 
Temp 39.7
Skin/coat -skin tent normal 
MSK NSF spinal comfortable 
Neuro NSF
Pulse = HR

Ddx
gastric upset 
diet indiscretion 
pancreatitis 

Plan
Discussed Ddx possibility with O
maixcam to reduce pain and pyrexia, prevomax to settle adbomeninal visceral pain 
INI tomorrow next step further diagnostics 

Date Requested: 24.02.26
LB/Tech Checked: jul
History Sent To (Insurance Company Or Clinic Email): goldengrove@vet4pets.com
Owner Consent: YES
Staff Initial: KG
Date Sent: 24/2/26

History: Presenting for 2nd puppy vacc
"Rubys puppies first vaccine 169333"
Medications:

Exam:
Demeanor: BAR, friendly
Cardiovascular: Rate 180bpm, nil murmur or arrhythmia. Gums pink & moist. CRT <2 secs
Resp: RR wnl, normal bronchovesicular sounds. No increased effort. 
Gastrointestinal: Abdomen soft and comfortable on palpation. Defecating normally at home. Eating well at home.
Musculoskeletal: R patella minor luxation felt G 1/4, not previously noted
Neurological: NAD. Full neurological exam not performed. 
Urinary: NAD. Urinating normally at home. 
Ophthalmic: NAD. Full ophthalmic exam not performed. 
Dental: Dental grade 0/4
Ears: NAD. Full otoscopic exam not performed. 
Skin: NAD.
Lymph nodes: submandibular WNL.
BCS 2.5/5
Repro: NAD

Plan: 
Healthy for C5, revisit in 3 weeks for C4
O/vet to monitor patella during growth to see if resolves or if needs surgery when older.