C09982671 / invoice 10000

Appointment Reason: 1.2 CONSULT 2, Appointment Notes: Limping on foreleg.  DDVet: ASBPresenting Concern: 9-year-old Kelpie presenting for an acute onset RFL lameness.HISTORY:-   Acute onset RFL lameness today.-   No specific trauma witnessed, but is a very active dog.-   History of arthritis which has previously been managed with monthly injections during winter but have been discontinued (suspect synovan or similar)-   History of a brown snake bite a few years ago.  EDDU: Normal  V/D/C/S: No V+ or D+. No coughing or sneezing.  Parasite Prevention: NexGard, up to date.  Vaccination Status: Up to date.  Current Medications: None  Additional Information:-   Lives on an acre property with another dog.CLINICAL EXAMINATION:Demeanor: BAR  Temp: not taken, HR: wnl, RR: wnl, MM & CRT: Pink & Moist, CRT <2 secs, BCS: 4/9  Hydration: No evidence of dehydration  Weight: 21 kg  Nasal: No nasal discharges.  Eyes: Clear, equal in size, no discharges. Normal vision.  Ears: Clean, no discharges.  Dentition/Oral: No abnormalities detected.  Cardiovascular: Normal rhythm, no murmurs/arrhythmias auscultated. Pulses strong and synchronous  Respiratory: Normal bronchovesicular sounds, no adventitious lung sounds, no increase in effort.  Lymphatics: Palpable lymph nodes WNL.  Skin: No abnormalities detected, No Hx of pruritus.  Abdomen: Comfortable, no pain response to palpable, no mass structures palpable.  MSK: Lame on the RFL. Pain was not localized to a specific area on palpation, however, there was some resistance on full extension of the right elbow.  Urogenital: External genitalia appear as normal, normal bladder on palpation.  Neuro: Normal gait, proprioception and mentation, full neurological exam not performed.  Rectal: not performedASSESSMENT:-   RFL lameness-   Differential diagnoses include an arthritis flare-up or a soft tissue injury.-   A fracture or bone cancer are considered less likely as there was no significant pain response on palpation. Radiographs would be needed to assess further.TREATMENT/ PROCEDURES:Dispensed Medications:-   Meloxicam oral liquid: Give the dose for a 21 kg dog (as marked on the syringe) SID with food for 7 days. Advised to stop medication and contact the clinic if any vomiting or diarrhea occurs.CLIENT COMMUNICATION/ PLAN:  -   Discussed that the plan is to trial a course of anti-inflammatory pain relief and strict rest.-   Re-assessment and radiographs of the RFL are recommended if the lameness does not resolve, worsens, or recurs after finishing the course of medication.-   Discussed long-term management options for her arthritis, including:    -   A course of Zydax injections.    -   Monthly Beransa injections.    -   Joint supplements.    -   Ongoing NSAIDs-   The O can contact the clinic to schedule an appointment for Zydax injections if they wish to proceed.-   Advised to call for a recheck if Rosie is not improving as expected.Notes written by AI and edited by ASB    Vital Signs    Weight: 21 (Patient Update);