C10017825 / invoice 10000

Appointment Notes: Booked Online: 11/03/2026 02:07:26 AMBooking Type: UnwellBooking Notes: Injury WEIGHT: 21kgReason: Presented for investigation of acute onset, non-weight bearing lameness of a forelimb.History: Ky presented today for lameness. The owner's brother took her for a walk yesterday, and she was reportedly normal during and after the walk. Later in the evening, the owner noticed she was "walking weirdly" but was not vocalising or showing overt signs of pain. Overnight or early this morning, the lameness progressed to being non-weight bearing on the affected limb. She was reluctant to have her paw handled, pulling away when the owner tried to examine between her toes. The lameness has shown some improvement throughout today, and she has started to put more weight on the limb as the day has progressed, though it still appears tender. There was no specific incident of trauma, such as an unusual run or jump, witnessed during the walk yesterday. She has not been taken for a walk today. The owner notes that when resting, she tends to hold the affected paw up.Diet: Not discussed.Current meds: None.Vaccination: Up to date.Parasite Prevention: Receives NexGard Spectra monthly and a three-monthly worming tablet.Pre-existing conditions: noneAccess to toxins eg. Rodenticide: noneEXAMINATION:Demeanour/Behaviour: Bright, alert, and responsive, though appears somewhat sore and apprehensive.Body Condition Score: Not assessed/9Pain Scale (0-4): 2/4HR: bpm, HR=PRRR: eupnoeicMM: pink, moist, CRT 1-2sHydration status (%): hydration clinically adequateCardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: neurologically no significant findings, full neurological examination not performedMusculoskeletal: Ambulates with a clear forelimb lameness, but is now partially weight-bearing. Palpation of the limb revealed discomfort with pressure over the elbow joint and some reluctance to have the carpal area handled. No specific point tenderness was elicited along the long bones. No crepitus, swelling, or obvious deformity noted. Examination of the paw pads and interdigital spaces revealed no foreign bodies or visible injuries. Full range of motion was difficult to assess due to discomfort.Gastrointestinal:Oral: normal, no mouth pain, dental score (1-4): Not assessedAbdominal: no detectable pain on abdominal palpation, no abnormalities noted, no hernia palpableRectal: not performedUrinary: nsfReproductive: nsfIntegument/Ears: nsfLymph Nodes: no peripheral lymphadenomegaly, nsfEyes: nsf; no redness, discharge or blepharospasmTemperature: Not taken degrees CelsiusDiagnostics: No diagnostics performed at this stage. Imaging was discussed as a next step if there is no improvement.PROBLEM LIST:1. Problem: Acute onset forelimb lameness, improving with time.ddx: Soft tissue injury (muscle strain, ligament sprain), minor fracture (e.g., greenstick), joint injury.Treatment Plan: Trial of rest and anti-inflammatory medication.Differential diagnosis / Diagnosis:Suspected soft tissue injury (myositis/ligamentous strain).Assessment:Ky is a young, active dog presenting with an acute onset forelimb lameness that has started to improve. The history of progressive lameness after a period of rest following exercise, combined with the gradual improvement in weight-bearing, is highly suggestive of a soft tissue injury, such as a muscle strain or ligament sprain. Examination findings of tenderness around the elbow support this. While a small, non-displaced fracture cannot be entirely ruled out without imaging, the clinical picture of improvement makes this less likely.Treatment:Meloxicam (Medicam) oral liquid: Dispensed. Dose at 20kg mark (21kg weight today) once daily with food for 7 days for anti-inflammatory pain relief.Gabapentin: Dispensed 20 tablets. Dose at one tablet twice daily (every 12 hours) for sedative and analgesic effects. Dose can be increased to 1.5 tablets twice daily, or frequency increased to every 8 hours if sedation is insufficient to enforce rest.Plan:1. Strict rest for one week. This includes no running, jumping, or boisterous play. All toilet breaks should be on a lead to control pace and prevent over-exertion.2. Administer Meloxicam and Gabapentin as prescribed.3. If lameness resolves, gradually reintroduce normal exercise over several days. Do not allow off-lead activity immediately.4. Re-check examination and likely radiographs (X-rays) are recommended if the lameness is not significantly improved or resolved after one week of treatment, or if it worsens at any point.Client Communication:Discussed the likely diagnosis of a soft tissue injury. Explained the rationale for conservative management with rest and anti-inflammatories as the first-line approach in a young dog with an improving lameness. Advised that imaging (X-rays) would be the next step if she fails to improve, which would assess for bone or joint abnormalities.Detailed instructions were provided for medication administration:Meloxicam must be given with food once daily. Advised to give a small amount of food, then the medication directly into the mouth, followed by the rest of the meal to ensure the full dose is received.Instructed to cease Meloxicam and contact the clinic if any vomiting or diarrhoea occurs.Explained the flexible dosing for Gabapentin to achieve adequate sedation for rest.Clarified Meloxicam is once daily and Gabapentin is twice daily. All directions are also on the labels.Advised to start both medications tonight. Owner understands the plan and when to return for a re-check.    Vital Signs    

Reason: General Health Check - Flea/tick/worming TXAppointment Notes: Overdue reminders    Vital Signs    Weight: 28.5;       

Reason: General Health Check - Flea/tick/worming TXAppointment Notes: Overdue remindersReason:General health check and parasite prevention script. Presented By Male OHistory:Last seen 6/12 ago (September 2025) for vaccinations. C3 and kennel cough UTD.O reports no concerns. Generally well. No V/D, C/S. Normal appetite and thirst.Previous history of self-resolving diarrhoea noted. Diet: RC adultCurrent meds: noneVaccination: UTD (last C3 and KC Sept 2025)Parasite Prevention: Nexgard Spectra monthly, requires 3month tapeworm - O aware and will buy todayPre-existing conditions: noneAccess to toxins eg. Rodenticide: none EXAMINATION:Demeanour/Behaviour: Bright, alert, responsive. Very good for exam thouigh rubbing face as does not like halti collar. No evidence of other cause of itchBody Condition Score: 4.5/9 excellent!Pain Scale (0-4): 0/4HR: 90bpm. Normal rate and rhythm, HR=PRRR: [30MM: pink, moist, CRT 1-2sHydration status (%): hydration clinically adequateCardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronous. No murmurs detected.Respiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: neurologically no significant findings, full neurological examination not performedMusculoskeletal: ambulating normally, no evidence of lameness. Good range of motion in hindlimbs and FL, good hip stance. Gait WNL, good sit posture.Gastrointestinal:- Oral: normal, no mouth pain, dental score (1-4): 0/4. Minimal plaque. O using dental chews. Good occlusion- Abdominal: soft, non-painful on palpation, no abnormalities noted, no hernia palpable- Rectal: not performedUrinary: nsfReproductive: nsfIntegument/Ears: Skin and coat in good condition. No abnormalities on ear exam. Coat smells, increrase bathingLymph Nodes: no peripheral lymphadenomegaly, nsfEyes: nsf; no redness, discharge or blepharospasm, symmetricalTemperature: NT Diagnostics:None performed. PROBLEM LIST:1. Problem: Nil apparent on physical examination.Treatment Plan: N/A 2. Problem: Parasite prevention.Treatment Plan: Continue current protocol. Differential diagnosis / Diagnosis:1. Normal on physical examination. Assessment:Ky is a healthy young dog with no abnormalities detected on clinical examination. Dental health is excellent for age. Treatment:Nil administered in consult. Plan:1. Dispense tapewormer for today and 3/12 time.2. Continue monthly Nexgard Spectra for heartworm, intestinal worms, fleas, ticks, mites.3. Advised O to re-present if any concerns.4. RV 6months time for GHC + vacciantions5. Discussed continued dental care +/- plaque off Client Communication:Discussed current parasite prevention protocol and importance of compliance. Advised Nexgard Spectra monthly for comprehensive coverage, with addition of a tapewormer every 3 months. Praised O's efforts with dental care (dental chews) and encouraged continuation. Advised tooth brushing is gold standard. Advised Ky is in excellent health.These notes were generated by AI (Program Heidi) and reviewed/edited by Dr Lauren Evill.--- 27/02/2026 10:35:12 AM CB4:Examinations - Resolved - SMS sent CB 27.02.2026    Vital Signs    MMColour: PM;       Weight: 28.5;       Temperature: NT;       HeartRate: 90;       BodyScore: 4.5/9;       DentalGrade: 0/4;       RespirationRate: 30;       CRT: <2;