C10013568 / invoice 10000

11/03/2026 NURSE: AM

REASON: Possible back pain

HISTORY:
- On Monday became sore - for 2hrs was trying to scratch/nibble flank or lumbar spine area, hasn't gotten much better since - similar to what she was like initially.
- Lethargic, wont play with toys and reluctant to jump.
- Eating, toileting fine, drinking normally.
- Ox concerned has jarred something. Does jump a lot.
- No V+ or D+.
- No limping, maybe was a little weak in them.
- No medication.
- UTD with flea tick worming.
- No issues with FL.
- Ox hasn't been walking her since Monday.

APPETITE: Eating fine.
ACTIVITY: Lethargic, wont play with toys, reluctant to jump. Normally crazy when ox comes home from work - nothing now.
TOILETING: Normal BMs, drinking normally.
CURRENT MEDICATIONS: Nil.

CLINICIAL EXAM:
- Mentation: QAR, anxious - loves treats.
- MM: Pink, moist.
- CRT: <1 sec.
- Oral and Dental Score: Grade 0, normal occlusion.
- Eyes: Bright, clear.
- Ears: NAD externally.
- BCS: 3/5
- Lumps: Not assessed.
- Abdominal: Tense, guarded but most likely anxiety related.
- Lymph nodes: Prescapular and submandibular LN WNL.
- HR: 102 bpm, normal.
- RR: Not assessed.
- Temp: 38.9°C.
- Urogenital: Not assessed.
- MSK: Lumbar spine - possible discomfort on first 2-3 vertebrae of lumbar spine. R hip comfortable, good ROM. L hip comfortable, good ROM. No obvious thickening around stifles. Good proprioception bilaterally. Digit 4 LHL - no nail bed trauma, no split of nail, no swelling or bruising, did growl on palpation. Stifles comfortable on palpation, no cranial draw bilaterally.
- Skin: Not assessed.

ASSESSMENT:
- Possible discomfort on first 2-3 vertebrae of lumbar spine.
- Clinical signs consistent with back injury rather than leg injury.

DISCUSSION:
- Ox to supervise at home after methadone administration - may make poor decisions due to sedation.
- Rest advised until at least Monday next week.
- If still noticeably less mobile, quiet and withdrawn despite pain relief and rest by Monday - return for review and imaging.

TREATMENT:
- Methadone - 4hrs pain relief.
- Injectable anti-inflammatory.
- Ongoing oral anti-inflammatories to go home.

PLAN:
- Strict rest until at least Monday next week.
- Recheck if no improvement by Monday.