C09972234 / invoice 10000

Reason: Sore Leg Appointment Notes: ongoing for while twAttendees: Gayle and KeithHistory:Has been limping on RFOn antinol rapid and fish oilsStill on pred dailyGabapentin not effective but only using sporadicallyNot wanting to play ballIs also becoming deafEating drinking urinating defaecating normallyNo vomiting/retchingNo coughing, no exercise intolerance, no breathing difficultyNo lameness, stiffness or sorenessNo itching and scratchingBright Alert ResponsiveBody condition score 6/7Examination:Mucous membranes – pink moist crt <2sOral cavity – clear, no evidence of ulceration, tongue normal, hard palate fineTeeth – grade 2Nasal planum – normal pigmentation and architecture, no crusting, no dischargeEyes – eyelid conformation normal, PLR normal, no chemosis,  no dischargeEars – no discharge, no erythema, pinna fine, otoscopically TM in tact with some wax build upLymph nodes - normalHeart – normal regular rhythm no pulse deficits, no murmur HR92Lungs – clear sounds bilaterally, no crackles or wheeze, tracheal pinch negativeAbdomen – comfortable on palpation, bladder normal, no masses palpatedLimbs – reduced extension in R elbow, poss slight discomfort rest of limbs all good range of movement, no swelling or pain on palpationNeck and spine – no pain on palpationSkin – no sign of erythema, no alopecia,  Nails – fine but nails starting to grown sideways on RFAnal glands – not scootingTemperature – not takenGenital region - no masses or swellingsDiagnosis:R elbow arthitisTreatment:Trial synovan injection seriesContinue on pred fish oils and antinolPlan: FUC daysAttendees:Nurse:Treatment: Synovan Injection - SC 0.#mlWhat week injection is this?:How is the patient going?:Any other concrens?:repeat in 4 weeks    Vital Signs    Weight: 11.6;