C09982397 / invoice 10000

Appointment Notes: limping HL this am - was in laundry last night - LB?????History: BIOP for 3 days. Presented for acute onset left hindlimb lameness, which started this morning. The puppy is otherwise bright, happy, and eating well. OExamination Findings:- Demeanour: BAR Weight: 3 kg Heart Rate:120 = PR, Respiratory Rate:28 , MM pink CRT<2s, Temperature: not taken BCS: 4/9- Eyes: NAD.- Ears: NAD.- Oral: WNL.- Nose: NAD.- Peripheral lymph nodes: WNL.- Cardiovascular: regular, no murmur.- Respiratory, breathing: normal effort, auscultation clear.- Urinary/Genital: normal external anatomy.- Skin: NAD, normal skin tent. Coat is wet.- Abdomen: soft, comfortable on palpation.- Rectal examination: not performed.- Neurological: Normal mentation, no ataxia, detailed exam deferred.- Musculoskeletal: left hindlimb G3/5 lameness observed. Palpation and manipulation of the right stifle elicited a pain response.Problem List:- Acute left hindlimb lameness- Pain on right stifle manipulationAssessment:Acute right hindlimb lameness in an 11-week-old puppy. Examination findings are localised to pain in the right stifle. The primary assessment is a soft tissue injury or sprain.ddx:- Stifle sprain/soft tissue injury (most likely)- Cruciate ligament tear (less likely)Plan:Treatment Plan:- meloxicam 0.1mg/kg PO q24h for 3 days. Must be given with food.- Strict rest for 3-5 days. Client Communications:- Discussed likely diagnosis of a sprain and the less likely possibility of a cruciate tear.- Advised on medication administration, stressing the need to give it with food to avoid stomach upset.- Emphasised the importance of strict rest for 3-5 days to allow healing.- Advised to re-present for a recheck if lameness worsens or does not improve after the 3-day course of medication.?????    Vital Signs    Weight: 3;