C10029132 / invoice 10000

13/03/2026 
Reason/concerns:  

History:
- Sore around bum/lower back for past 2 weeks 
- Dragging bum around carpet 
- Diet: steak 
- Loss of appetite past few days 
- Hasn't been to the toilet for the past couple of days 
- Occasional D+ but not recently - few wks ago was the last one 
- No V+ 
- no other concerns at home 

Pre-exisitng Conditions / Medications: Nil 


Examine: 
Mentation: BAR
BCS:                           /9   
MM: Pink          
CRT: 1-2 seconds
HR:                  130           beats/min
RR:                             breaths/min
Temperature:     39.1         degrees Celsius

Ocular: No abnormalities noted on cursory examination of both eyes.
Oral/Dental stage: x  gingivitis and calculus observed. Gx/4 dental disease. 
Ears: No abnormalities noted on cursory examination of both ears.
Cardiovascular: No audible murmur or arrhythmia and no difficulty hearing the heart. HR = PR and no evidence of hypoperfusion.
Respiratory: Respiratory rate and effort considered normal for the patient.
Gastrointestinal: No pain on abdominal palpation. No masses or abnormalities palpated.
Integumentary: No significant abnormalities.
Musculoskeletal: Normal gait and strength noted. No evidence of lameness.
Urogenital: No significant abnormalities noted during routine physical examination.
Neurological: No evidence of neurological impairment or altered mentation. Detailed neurological examination not performed today.
Lymph nodes: Within normal limits for mandibular, prescapular and popliteal examination.

Problem List:

Patient Assessment: 

Diagnostics performed (i.e. bloods, radiographs/ultrasound, ear cytology, urinalysis):
- None performed 

Treatment with medication dose rates (if any):

Client Communication & Plan: 
- gaba 
- Monday AG 
- condier TAHP 
- consider pumpkin 

On-going medications required: Y/N (use prescription tab for further supply):

Next check up date: