C10018664 / invoice 10000

HISTORYPresenting for: Small dog presented for crying in pain, particularly when approached, with decreased appetite including missing breakfastDiet:- Decreased appetite, missed breakfast (not unusual for this patient)Current Meds:- Has a newborn at home, other dog in householdEXAMlimited OPE allowable d/t nervous temperament so went slowlyMentation: BARWt: 10.4 kgT: 39.2°C - slightly elevated but within acceptable range for anxious/excited dogBehavioural: Nervous, shaking, anxious during examinationThroat: mild swallow elicted on neck palpation, no hacking or gaggign though, brief oral exam when yawning, no overt inflamm notedOral: Examination performed - no significant findingsLymph Nodes: All lymph nodes palpable and normalIntegumentary: Thorough palpation of head/neck area performed - no moisture, dry areas, wounds or injuries detected through hairASSESSMENTFacial/oral pain - DDx: tonsillar foreign body, infectious canine tracheobronchitis, masticatory muscle myositis, temporomandibular joint dysfunction, muscle strain/sprainPLANNew Meds/Tx:- Metacam 0.41 mL subcutaneous injection administered today for anti-inflammatory and analgesic effect. Expected onset within 30-60 minutes with 24-hour duration. Comparable to diclofenac for pain reliefDiet Recs:- Soft food recommended for this evening- Avoid rough and tumble activity for 1-2 hours until medication takes effectClient Comms:- Phone contact within 24 hours to assess response to treatment- If significant improvement occurs, may discontinue medication and monitor- If partial improvement or worsening, further diagnostics including blood work with inflammatory markers (CRP) and sedated oral examination may be recommended- Emergency presentation advised if condition deteriorates - inform emergency clinic of anti-inflammatory administration- Sedation options available using anxiolytic protocols (dom/meth & ketamine/valium combination) if further examination required    Vital Signs    

Spoke with Cheyenne when she was in with other dog WormHas run out of fluoxetine for Freddy. Feddy is due for 6 month health check,  and was due for vax at his last visit and wasn't vaccinated. Have apologized to owner for our oversight. Have written a script for Worm's fluoxetine today, and suggest that she could use Worm's fluoxetine for Freddy meanwhile, and bring Freddy in when she is able to in a couple of weeks for his health check , vaccination, and repeat meds    Vital Signs    

Reason: PrescriptionSubjective: presented for 6mth health check and fluoxetine script, O has no concerns - EDDU normal, no V+ or D+- Has been on fluoxetine for 6mths, O says is really helping - O says has back pain from previous fall but isn't too concernedObjective: FAS: 2/5, shaking but good if you go slowly HR/PR: 80bpmTemp: not assessedMM: pink and moist CRT: <2 secs PULSE: strong and synchronous C/V: normal cardiovascular auscultation with no audible murmur RESP: no abnormal respiratory sounds or effort noted Hydration: adequate GIT: soft and comfortable abdominal palpation U/G: nad Skin/Ears: nad M/S: did not assess (didn't want to cause further stress) Eyes: nad Dental: did not assess Other: LN WNLAssessment: fit for fluoxetine script- Discussed importance of blood profile on long-term meds. O interested but didn't have funds for today, will do blood profile at next visit Plan: fluoxetine 20mg tablets, 1 tab SID, script for 6mths    Vital Signs