C10011385 / invoice 10000

10/03/2026 REASON- GHC + vaccination 

HISTORY-
Presenting for vaccination today. 
Lately has been getting quite stiff after prolonged periods of rest. Both front and back legs. Eventually loosens up too. 
Has been going on for the last couple of months. 
Once moving about seems okay, running around at the park normal. 
EDDU - normal. 
No recent V+, D+, coughing or sneezing. 
UTD flea/tick prevention - NG spectra

BAR - anxious girl!
BCS 6/9
HR:  140bpm, grade 2/6 cardiac murmur auscultated. Pulses S+S
RR:   panting, normal respiratory sounds and effort. 
T:    not performed
CRT: 1sec    
MM: pink & moist
EYES: NAD
EARS: NAD
NOSE: NAD
ORAL EXAM: Grade 1/4 periodontal disease. Mild tartar, nil gingivitis. 
SKIN:  NAD
ABDOMINAL PALPATION: Tense with palpation. 
MUSCULOSKELETAL SYSTEM: Crepitus over hocks and stifles, comfortable with ROM in hips. Resenting manipulation of forelimbs, did not tolerate. 

ASSESSMENT:
Fit for vaccination
Low grade cardiac murmur
Stiffness DDx: OA vs. soft tissue injury vs. neoplasia vs. other

PLAN:
- Pain relief trial with NSAIDs to see if it helps resolve stiffness. Recheck indicated next week to assess progress and get long term plan (ideally perform chem11 at recheck for NSAID pulse dosing +/- start synovan course)
- Offered leptospirosis, O declined today. If interested will start course next week. Discussed risks. 
- Dispensed trazodone for vet visits, Shelby very anxious and not tolerating PE well. 

Rx:
MSD Nobivac DHP + Bb/Pi - 2528102 exp: 06.27
100mg trazodone PO x calm protocol
20mg onsior SID x 6 days