C09977889 / invoice 10000

HISTORY: yesterday playing ball, non-weight bearin left FL
Approx 1 hour ater
Never problem with this or other legs in past
No obvious trauma
Anal glands
Diet =
H/W prevention, intestinal worming, flea control = milbeamx and bravecto quantum
Vomiting = one off 2 days ago (bile)
Diarrhoea = no
Changes in appetite = no, normal appetite when legs painful
Changes in water consumption = no
Coughing or sneezing =
Change in exercise tolerance =
Lameness = see above
Weight = 7.7kg

EXAM: Mentation = anxious
HR =PR=124, colour pink, CRT 1 sec, femoral pulses normal, thoracic auscultation clear
BCS = 6/9
DS = 1-2/4
Eyes = NAD
Ears = normal
Skin and perineum = good currently
LNs = normal
Abdominal palpation = no pain nor abnormality, normal gut sounds
Orthopaedic exam = mild left FL lameness in clinic with no change post orthopaedic exam
Normal range of motion all joints, no effusions nor instability, no obvious long bone pain/instability, digits/nails/footpads all NAD
Repeatable pain on extension left FL, no pain on same exam with right FL

ASSESSMENT: left FL lameness, acute onset- elbow pain

PLAN: discussed elbow pathology in detail including dysplasia, 1st episode (one previous exam licking left carpus but no lameness so ?)
At this stage 1st clear episode, acute and improved in first 24 hors soft tissue as likely as any
Consider radiographs if worsens, acutely returns or doesn't completely resolve
Discussed rest alone v/s test + nSAIDs, discussed nSAID side-effects
Home meloxicam 0.45mL PO sid with food
Recheck as required