C10021328 / invoice 10000

painful left hind leg
Not limping, just paiful to palpate

Primary/Suspect diagnosis/location: (Acute pain in left hindlimb)
Suspect cause: (Trauma. Dog no longer showing signs of pain on clinical exam.)
Any other conditions being treated [if any]: (nil)
Known health concerns: (nil)
Date of first clinical signs [if known]: (12/3/26) 

History:
Reason: ()
Diet: ()
Preventatives: ()
Medications: ()
EDDU: ()
Coughing/Sneezing: ()
Vomiting/Diarrhoea: ()
Current Diagnoses: ()
Hx:
()

Examination:
DEMEANOUR: ()
MENTATION: ()
GENERAL: BCS: ()/9; HR: (); RR: (); MM: p,m; CRT: <2; T: ()
EARS: no discharge, swelling or erythema
EYES: no discharge or erythema
NOSE: no discharge
ORAL: no discharge or halitosis; ()/4 dental disease
CV: no murmurs or arrythmias
RESP: clear bronchovesicular sounds on all fields with normal effort
ABDO: comfortable; no palpable abnormalities
UROGEN: no discharge or swelling
MSK: normal gait
NEURO: no gross defecits noted
DERM: no external parasites; good coat; no lesions, pruritus or erythema
LYMPH: no peripheral enlargement
RECTAL: not assessed

Problem list:
()

Diagnostics:
()

Assessment:
()

Client Communication:
()

Treatments:
()

Plan:
()

Discharge Instructions:
()

Health Check / Vaccination
Paws App Details:

- NEW CLIENT -

Booking Type: Vaccination
Booking Notes:  Health check and vaccination 
Owner May we request your pet's history?: Yes
Owner Can you provide your previous Vet Clinic's name?: Warwick Vet Clinic

Pet Insured: Yes
Pet Insurance Provider & Policy no (if applicable & not provided): Petsure CB19746003

History:
Reason: (vaccination)
Diet: (kibble sid in the morning)
Preventatives: (simparica trio not utd)
Medications: (nil)
EDDU: (normally)
Coughing/Sneezing: (nil)
Vomiting/Diarrhoea: (nil)
Current Diagnoses: (nil)
Hx:
(Presentign for vaccine, usnuire what has had in the past, not utd maybe month or 2 over on simparica )

Examination:
DEMEANOUR: (freidnly -noodle)
MENTATION: (BAR)
GENERAL: BCS: (7)/9; HR: (110); RR: (pant); MM: p,m; CRT: <2; T: (39.1)
EARS: no discharge, swelling or erythema
EYES: no discharge or erythema
NOSE: no discharge
ORAL: no discharge or halitosis; (0)/4 dental disease
CV: no murmurs or arrythmias
RESP: clear bronchovesicular sounds on all fields with normal effort
ABDO: comfortable; no palpable abnormalities
UROGEN: no discharge or swelling
MSK: normal gait
NEURO: no gross defecits noted
DERM: no external parasites; good coat; no lesions, pruritus or erythema
LYMPH: no peripheral enlargement
RECTAL: not assessed

Problem list:
(nil)

Diagnostics:
(nil)

Assessment:
(fit for vaccination)

Client Communication:
(recc. needs to be utd on tick prevention, and needs to be given monthly
recc. tapeworming
recc. reducing food from 2 cups to 1 & 1/2 cups)

Treatments:
(vaccinated with nobivac flex DHP SC; B:(2519605), E:(07-27), L:(inbetween shoulder blades)
vaccinated with nobivac KC; B:(2511209), E:(12-27), L:(intranasal)
)

Plan:
(vaccination due in (dhp 3yr,, Kc 1yr)
worming due in (O to do - today)
flea/tick prevention due in (O to do today)

Discharge Instructions:
(nil)

Verified: NO

History:
Reason: 
Diet: 
Preventatives: 
Medications: nil
EDDU: 
Coughing/Sneezing: no
Vomiting/Diarrhoea: no
Current Diagnoses: 
Hx:

Examination:
DEMEANOUR: 
MENTATION: 
GENERAL: BCS: /9; HR: ; RR: ; MM: p,m; CRT: <2; T: 
EARS: no discharge, swelling or erythema
EYES: no discharge or erythema
NOSE: no discharge
ORAL: no discharge or halitosis; /4 dental disease
CV: no murmurs or arrythmias
RESP: clear bronchovesicular sounds on all fields with normal effort
ABDO: comfortable; no palpable abnormalities
UROGEN: no discharge or swelling
MSK: normal gait
NEURO: no gross abnormalities
DERM: no external parasites; good coat; no lesions, pruritus or erythema
LYMPH: no peripheral enlargement
RECTAL: not assessed

Problem list:

Diagnostics:
nil

Assessment:
stable on exam

Client Communication:

Treatments:

Plan:

Discharge Instructions: