C10031230 / invoice 10000

limping/walking funny
GK pls



Verified: NO

Consultation for gait abnormality and behavioural assessment

Reception notes: 

Today's attendee/s: Owner

No

History: 10-month-old dog presenting with gait abnormalities noticed during training sessions. Owner reports the dog kicks out his right leg/stifle and has concerns about patella. Dog has anxiety issues and is currently on anxiety medication. Shows reluctance to walk, tends to walk behind rather than in front, and becomes distressed with certain sounds or movements. Owner notes he doesn't run and has difficulty with certain movements like jumping fully onto furniture despite being able to get his paws up.

EDDU: Eating well: Yes, PD/PU: . , Urination & Faeces: Normal 
Diet: 
V+/D+: No 
Worming: unknown 
Heartworm: 
Ectoparasites: NexGard Spectra 

Examination:
Temperament: Anxious, shows distress with certain sounds and movements 
Weight: 7.7 kg
BCS: ,   
Mucous Memb: Nice and pink 
CRT: sec 
TEETH: Beautiful, no tartar, dental grade 
EYES: 
EARS: 
Nares: 
SKIN: 
UROGENITAL: 
LN: 
HR: 110 bpm; = Pulse rate Yes 
H MURMUR: No 
H RHYTHM: 
RR: bpm  Effort 
CHEST AUSC: 
ABDO PALP: 
ANAL SACS L: , R: 
MUS/SKEL: Abnormal gait with wider base stance, kicks out right leg more than left, some resistance on manipulation, comfortable palpation of soleus muscle, patellas feel good and cannot be luxated, no discomfort in foot or stifle, suspected issue in lumbar hip region 

Assessment: 
- Abnormal gait in 10-month-old dog with wider stance and asymmetric leg movement
- Suspected hip or lumbar spine pathology
- Normal patella examination
- Behavioural anxiety issues

DDx: Hip dysplasia, lumbar spine disease, congenital musculoskeletal abnormality 
Laboratory: 
Treatment: 

Plan: 
- Book sedation and PenHip X-rays to assess hip laxity and rule out hip dysplasia

- If hips are normal, consider advanced imaging (CT/MRI) for spinal assessment
- Continue current anxiety medication
- Estimated cost approximately $1000 for PenHip procedure

Recheck: Following PenHip X-ray results 

This record created with the assistance of Vetnotes incorporating AI, with the attendee's permission.

Walking Video

Dispense 56 Fluoxetine tablets, 1/2 sid

Meds Request for (Fluoxetine)   Taken by (TNE)

Drug (Fluoxetine)  
Form (tabs)  
Strength / Concentration (20mg)   
Pack size (28)   
Number of Units  () / No of Packs  (2 pls)
Dose ()

Notes [please initial] ()

Copy and paste the above for multiple requests. Another copy below.

Vet to complete and / or change if necessary so it becomes a record of what was actually dispensed. Use the notes field to record conversation with client etc.


Vet Checklist  - See description list - MEDS_VETCH   


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Drug ()  
Form ()  
Strength / Concentration ()   
Pack size ()   
Number of Units  () / No of Packs  ()
Dose ()
Notes [please initial] ()