C09971286 / invoice 10000

HISTORY
Presenting complaint:
- Limping/lifting left hind leg after jumping off couch, mild lameness.
Diet and appetite:
- Not discussed.
History of presenting complaint:
- Alfie reportedly jumped from the couch earlier in the day while under supervision of owner's son.
- Limp and licking at left hind leg noticed on return.
- Mild to moderate lameness, able to bear some weight and walk, worsened with rising from rest.
- No history of similar issue prior to today.
- No observed trauma or obvious pain on manipulation; no significant acute distress.
Current medications & medical conditions:
- Past anal gland issues.
- Owner-reported sensitive stomach.
- No kidney disease reported.

PHYSICAL EXAM
Mentation: BAR
Eyes: NAD
Ears: NAD
Nose: NAD
Oral: pink mucous membranes, CRT <2 seconds
Lymph nodes: NAD
Cardiac: NAD
Respiratory: NAD
Abdominal: NAD
Genitourinary: NAD
Musculoskeletal:
- Mild lameness left hind leg
- No palpable fracture or luxating patella on examination
- No evidence of cranial drawer or significant instability
- No swelling, wounds, or foreign body appreciated
- Both stifles stable on manipulation
Neurological: NAD
Skin & Coat:
- NAD
Anal Sacs: NAD
Temperature: NOT TAKEN
Body Condition Score: NOT MENTIONED
Notes:
- Body weight recorded as 8.5 kg
- No signs of severe pain or distress

DIAGNOSTICS
Clinical Examination

ASSESSMENT
- Mild left hindlimb lameness post-jump, likely soft tissue injury (e.g. muscle strain or contusion)
- No clinical evidence of fracture, patella luxation, or ligament injury on today's exam
- Previous stomach sensitivity and anal gland history noted

TREATMENT
- Non-steroidal anti-inflammatory prescribed as an oral solution, given with food, once daily for 7 days
- If signs worsen or do not improve, radiographs/x-rays recommended for further evaluation
- Owner advised to monitor appetite and drinking and to discontinue medication if vomiting or diarrhoea observed
- Rest from jumping and vigorous activity recommended during recovery period

COMMS
- Discussed potential for soft tissue injury versus orthopaedic injury; owner advised of signs to monitor and when to re-present
- Owner instructed to return in approximately 7 days or sooner if worsening observed or no improvement
- Monitoring for gastrointestinal side effects due to history of sensitive stomach
- Advised medication can cause gastric irritation if given on empty stomach
ADDITIONAL INSIGHTS: None