C10024277 / invoice 10000

WEIGHT: 6.10
HISTORY: PRESENTING COMPLAINT: Tail held at half mast, sad looking tail

HISTORY: Owner noticed tail abnormality on Tuesday (3 days ago). Dog reacts when tail is touched but otherwise happy and eating well. No yelping or crying unless tail area is touched. No swimming prior to onset. No witnessed trauma or falls. Dog is 4 years old. Able to defecate normally, good mobility otherwise, can jump up and down normally. No blood or discharge observed. No other dogs or cats in household.

Current medications: 
Diet: 
Parasite prevention: 
- worms: 
- fleas/ticks: 
- Heartworm: 

Behaviour in Consult: Good natured, reactive only when tail touched
Mitigated by: 

EXAMINATION:
Weight: 6.1 kg
Weight change: 
BAR     BCS /9
Temp:     HR:     RR: 
Oral MM & CRT: MM Pink CRT <2 FP = synchronous, normodynamic
C/V: 
RESP: 
GIT: 
URINARY: 
NEURO: 
M/S: Gait: Abnormal tail carriage - held at half mast with kink in mid-tail area  Orthopaedic: 
INTEG: No wounds found on tail examination, small palpable bump in mid-tail area possibly due to trauma or inflammation    Lumps: 
OPTH: 
OTIC: 
DENTAL: Gde /4 periodontal disease 
LNs: 
OTHER: 
- Tail tip not hard or crusty
- No swelling in anal gland area
- Can sit normally with tail bending upward
- Pain localized to mid-tail area in fluffy portion

ASSESSMENT:
- Tail trauma/injury - mid-tail region
- Rule out tail fracture, limber tail syndrome, soft tissue trauma

TREATMENT: 
Laboratory: No

PLAN:
Sedation and radiographs offered but declined for now
Meloxicam 1 tablet once daily on empty stomach, wait 30 minutes before feeding
Codeine 0.7-2ml (starting dose 1ml) once or twice daily as needed for pain

CLIENT COMMUNICATION:
FU required/date scheduled: Yes - recheck Tuesday if not improved, veterinarian available Saturday 9am-4pm if needed
Dental/surgeries/procedures estimates: 
Estimate valid: 30 days
- Monitor for improvement over weekend with pain medications
- Avoid lifting dog by scooping under tail area
- Watch for constipation with codeine use - give moist food if needed
- Contact clinic if condition worsens or no improvement
- Pain relief approach appropriate even if fracture present as treatment would be conservative management

NOTES: DS called to check in - 2 weeks since starting fluoxetine.
No abnormal behaviours seen. 
Eating normally. 
Happy to continue on as prescribed, aware takes 6 weeks to be maximally effective.

HISTORY: HISTORY: 
Here for vaccs.
Also very concerned about separation anxiety - barking/crying/ urinating in house when people leave him.
Have started taking him in the car when leaving the house on errands as worried about him.
Fussy eater, always has been, has had a couple of vomits in the last 2 weeks, usually bilious.
Been well, no concerns, EDDU all normal, no V+D+, no coughing, no sneezing, no ocular discharge, no changes in appetite or thirst.
Mobility: great, no issues

Diet: Blackhawk kible
Medications (mg/kg): nil

Parasite prevention-
- Flea/tick prevention: brav quantum
- Worming : milbemax
- Heartworm : proheart annually

Behaviour in Consult:  normal, good boy for everything
Mitigated by: loved chicken churu paste


EXAMINATION:
BAR   BCS   5/9 
Temp  38.2C   HR 120     RR 16     MM Pink      CRT <2    FP = synchronous, normodynamic
C/V: Normal heart sounds, regular heart rhythm
RESP: Normal respiratory effort, clear bilateral lung sounds
GIT: Comfortable on abdominal palpation, nil palpable masses or foreign bodies
URINARY: NAD
NEURO: NAD
DENTAL: G 2/4 - gingivitis seen on molars and upper canines
OPTH: NAD
INTEG: NAD
OTIC: NAD
LNs: NAD
M/S: NAD
OTHER: 

ASSESSMENT:
Separation anxiety
Grade 2 DD
Clinically suitable for vaccination

TREATMENT: 
Triennial Vaccine given today:
Vanguard C4 - Given SC R scapula
Batch no: 00302
Exp: 11/2027
Vanguard B-Oral - Given orally

Proheart SR12/Afilaria - Given SC

Bravecto quantum given SQ after emla - such a good boy

COMMENCE MEDICATIONS:
Fluoxetine 10mg (1.3mg/kg) PO SID
Trazodone 25mg PO (4mg/kg) 2 hrs before leaving home

PLAN:
Training - positive reinforcement for toilet training outside again, praise when urinates outside, give treats, train 'go wee wee' or similar
Leaving routine to be established, always get a treat when leave, knows to get on his bed etc
If struggling with training recommended positive reinforcement trainer to come into home and give tips
Triennial due in 3 years.
KC/PH/brav quantum booster in due 12 months.

RECOMMENDATIONS:
- Diet/weight management: continue current
- Dental prophy: advised dental, to do as soon as practical, aware of 15% dental promotion
- Wellness tests: PABs before dental otherwise recommend bloods in 6 months if ongoing use of fluoxetine

OTHER:
Microchip on file: Y 
Pet Insurance: N

Dental estimate provided: Grade 2/4 - $1482-2900
(Estimate valid:  30 days)

CLIENT COMMUNICATION:
FUC required: N
WEIGHT: 6.60