C10022748 / invoice 10000

Reason: LimpingAppointment Notes: Booked Online: 10/03/2026 21:47:52 PMBooking Type: UnwellBooking Notes: Limping, not moving as usual. Owner Name: Amanda MorganOwner Email: russandaj@gmail.comOwner Mobile Number: 0418732203Pet Name: NyaPet Species: DogWeb BookingClient name: MorganContact number: 0418732203Email address: russandaj@gmail.comPatient name: NyaHISTORY:  Presenting for investigation of a one-week history of hindlimb lameness and stiffness. The owner reports Nya is struggling to jump onto furniture and navigate steps, particularly going up. Whimpering is noted occasionally, especially after long periods of rest. The owner initially suspected a UTI due to licking of the genitalia, but this behaviour has decreased and there are no other urinary signs like increased frequency. The lameness is generalised to the hindlimbs, possibly alternating, and does not seem to have improved over the week. The stiffness is most apparent in the mornings and after rest. No vomiting or diarrhoea reported. Owner also notes Nya has been more tired in the evenings. Current meds: Cortavance spray once weekly in ears.Vaccination: UTD, Due end of July.Parasite Prevention: UTD. Simparica Trio monthly.Pre-existing conditions: History of ear infections.Access to toxins eg. Rodenticide: none EXAMINATION:Body Condition Score: 6/9 (was previously 12.7kg, now 11.9kg)Pain Scale (0-4): 1/4Hydration status (%): hydration clinically adequateRespiratory: respiratory effort normal, no nasal dischargeNeurological: neurologically no significant findings. No conscious proprioceptive deficits or foot dragging noted.Musculoskeletal: Ambulating with a shortened stride in the hindlimbs. Reduced flexion of both hips, more pronounced on the left side, causing tensing. Palpable muscle knots noted in the lumbar/hip/iliopsoas regions bilaterally, with associated discomfort on palpation. No crepitus or obvious joint swelling.Gastrointestinal:- Oral: normal, no mouth pain, dental score (1-4): grade 2 on the canines, 0.5 on the other teeth- Abdominal: no detectable pain on abdominal palpation- Rectal: not performedUrinary: NSFReproductive: NSFIntegument/Ears: Both ear canals are clean, non-odorous and without inflammation. No evidence of active infection.Lymph Nodes: NSFEyes: NSFDemeanour/Behaviour: Bright and alert, became more active after massaging the knots during examination. PROBLEM LIST:1.  Chronic, progressive hindlimb lameness and stiffness (1 week duration).2.  Pain on palpation of lumbar region and hip flexion.3.  Grade 2 dental disease, primarily affecting the upper canines.4.  Overweight Body Condition Score. DIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:Suspected osteoarthritis of the hips.Potentially exacerbated by overexertion (soft tissue injury) DIAGNOSTICS:None performed today. Discussed potential for hip radiographs under general anaesthesia to confirm osteoarthritis. ASSESSMENT:Nya, a 7.5-year-old female desexed Cavoodle, presented with a one-week history of hindlimb stiffness and reluctance to jump. Examination findings of bilateral hip discomfort on flexion, particularly on the left, and a stiff hindlimb gait are highly suggestive of pain secondary to osteoarthritis. The pattern of stiffness after rest further supports this suspicion. While a UTI was an initial concern for the owner, the lack of clinical signs makes this less likely. Examination also revealed grade 2 dental disease on the canine teeth. TREATMENT:  No medications prescribed today.Discussed management strategies for osteoarthritis, including a stepwise approach.1.  Conservative Management: Lifestyle changes and supplements.2.  Injectable Medications: Synovan or Beransa.3.  Oral NSAIDs (e.g., Meloxicam) as a last resort due to potential long-term side effects.Recommended starting with conservative management. PLAN:- Owner to commence conservative management for suspected osteoarthritis. This includes starting a joint supplement (e.g., 4Cyte Liquid, Antinol, Rose-Hip Vital) and/or transitioning to a prescription joint care diet (e.g., Royal Canin Joint Care, Hill's j/d).- Institute a regular, low-impact exercise program (e.g., short, daily walks on leash) to maintain mobility and muscle mass, and aid in weight management. Avoid high-impact activities like jumping.- Re-evaluate progress. If there is insufficient improvement, consider commencing a course of Synovan injections (once weekly for four weeks).- Discussed possibility of hip radiographs if Nya is anaesthetised for another procedure in the future, such as a dental scale and polish.- An estimate for a Stage 1 dental procedure (scale and polish, dental X-rays, pre-anaesthetic bloods) will be emailed to the owner.- Home into owner's care. CLIENT COMMUNICATION:Discussed the clinical suspicion of osteoarthritis as a progressive, degenerative condition with no cure. Explained that management is focused on pain control, maintaining quality of life, and slowing progression. Outlined the three-step approach to management, starting with supplements and lifestyle modification, then injectables (Synovan, Beransa), and finally oral anti-inflammatories as a last resort for chronic use. Provided names of recommended supplements and diets.Advised on the importance of weight management and regular, controlled exercise.Discussed the finding of dental disease and the need for a general anaesthetic for a scale and polish. Explained the process of a Stage 1 dental, including dental X-rays, and the concept of staged extractions if required. Provided an estimate for the dental procedure to be sent via email.Discussed the Healthy Pets Plus wellness plan and its potential benefits, including discounts on procedures and free consultations. Provided a brochure.Owner understands the plan and will monitor Nya's progress at home.    Vital Signs    Weight: 11.9;