C10021719 / invoice 10000

Appointment Reason: Recheck, Appointment Notes: ?KJ6/3 LMOM - please move Diego's appt from Monday with YM to HR on Sunday. HR oked sun appt>KJ6/3 changed to sun appt.KJ????SUMMARY* Recheck for a 4-year-old Dachshund with a spinal injury, non-ambulatory since Tuesday but neurologically stable with deep pain intact.* Presumptive diagnosis of intervertebral disc disease with spinal cord compression.* Continuing multimodal medication. Commencing home physiotherapy and referred for hydrotherapy, with a recheck in two weeks.History:History: Diego presented for a recheck following an acute spinal event on Monday. He has been non-ambulatory since Tuesday morning. The owner reports he is defaecating, though it was less frequent early in the week. Urination is occurring, and the owner is using nappies. Diego seems calmer and more relaxed today compared to Monday's visit. He continues on Prednisolone, Gabapentin, Trazodone, and Paracetamol.Exam:Demeanour: BAR, more relaxed and less anxious than at previous consult.Vital signs:- Heart Rate: 120 bpm- Respiratory Rate: not done- Temperature: not done- Eyes: eyes clear, no signs of conjunctivitis, pupils symmetrical and normal size- Ears: vertical ear canals clear, full otoscopic exam not performed today.- Oral: Mucous membranes pink, moist CRT <2s.- Nose: nares clear, no discharge- Peripheral Lymph nodes: no peripheral Lymph node enlargement palpated- Cardiovascular: No heart murmurs auscultated, normal rate and rhythm.- Respiratory: normal lung sounds with no crackles / wheezes- Skin: Skin condition is good; noted as the best it has been seen.- Abdomen: relaxed on abdominal palpation, no masses or organomegaly noted. Bladder palpated and found to be fairly empty.- Rectal examination: not done. temperature not taken- Musculoskeletal: Non-ambulatory paraparesis. Deep pain reflex present in hindlimbs. Limited passive range of motion observed in hindlimbs.- Other Findings: A fentanyl bandage was removed from his leg.Laboratory tests: not applicableProblem List:* Hindlimb paraparesis stage 4 spinal disease* Spinal pain (suspected IVDD)Assessment:* Recheck for suspected intervertebral disc disease (IVDD) causing spinal cord compression.* Neurologically stable with deep pain perception intact.* Bladder control is present, a positive prognostic indicator.* Appears more comfortable on current multimodal pain management.Treatment:* Continue current medications at the same dose: Prednisolone, Gabapentin, Trazodone, Paracetamol.* Home physiotherapy exercises (passive range of motion 'bike riding' motion) to be started, aiming for three times daily.* Gentle massage of lumbar muscles recommended.* Referral to Hydro Hounds for hydrotherapy assessment - referal form filled in Client communications:* Discussed pathophysiology of spinal cord compression and the significance of deep pain and bladder control being present.* Advised that improvement is hoped for over the next 2-6 weeks, but conservative management is not always successful.* Recommended hydrotherapy to aid recovery and provided a referral letter for Hydro Hounds.* Discussed medication costs and the option for a gap claim. Owner advised to check their insurance policy regarding coverage for hydrotherapy.Plan:* Recheck consultation booked for Friday, 27th March at 8:30 am to reassess neurological status and progress.Additional:- Prognosis for a full return to normal function remains guarded.Notes to reception:* Recheck appointment booked for Friday 27/03/2026 at 8:30 am.owner declined to take more meds today depite offering to gap claim later in the week. will run out prior to next appt, ok to repeat all at current doses - traz 100mg TIDgaba 100mg 7 am and 1pm, 200mg before bedpred 2.5mg ( 1/2 a tablet SID)paracetamol 3mls TID10/03/2026 11:53:50 AM TB:F/U text sent11/03/2026 2:26:44 PM CZ:Insurance Claim Completed for this Visit?????    Vital Signs    Weight: 10.28;       

05/03/2026 5:14:24 PM CG:Roz came in to pick up the Gabapentin07/03/2026 4:06:55 PM 2HR:NOTE THIS IS INCORRECTLY CHARGED, HAS ONLY BEEN CHARGED 1 TAB not 100 11/03/2026 11:26:46 AM CZ:Correct price for 100 x gaba 100mg ($52.30) but kept at original price, as our mistake. 11/03/2026 2:26:44 PM CZ:Insurance Claim Completed for this Visit??    Vital Signs