C09983475 / invoice 10000

Appointment Notes: VETSTORIA -  - Lola Lowe (Dog) - Emily Lowe - 0468898071 - Consult - General (Sick) [Clinician : Dr Tara (Preferred Clinician)] - Sore toe / now RHLHISTORY:Doing well: Eating, drinking and toileting normallyCurrent Medications: Yes - Meloxicam (given for 3 nights previously, 1 dose given last night)Medical conditions: NoVomiting or diarrhoea: NoAny Concerns: Yes - R hind limb lameness started last night (sudden onset). Previously presented Friday afternoon for similar issue which resolved, then recurred. No improvement noted with Meloxicam dose given last night. Still very sore.Diet: Appetite and thirst: Flea/tick: Worming: Other relevant history: Overweight - noted to have extra padding, weight loss recommended. O reports patient is clingy, slept in O's arms overnight.EXAMINATION: Demeanour: BAR MM: Pink, moist, CRT <2 Eyes: Clean and clear, normal eyelids, no erythema or discharge.Ears: Minimal debris, no inflammation or odour.Lymph nodes: Peripheral lymph nodes palpably normal Oral: No oral lesions or abnormalities detected.Teeth: Dental grade /4, normal occlusion. COHAT Level Estimated: (A, B, C, D, E) Cardiovascular: Normal heart sounds, no murmurs or arrhythmias detected, femoral pulses synchronous and normodynamic.Respiratory: No nasal discharge, normal bronchovesicular lung sounds in all 4 quadrants, no coughing seen.Abdomen: Soft and comfortable on palpation, no masses palpated, bladder unremarkable.MSK: R hind limb lameness. No swelling, pain, or abnormalities noted in digits or paws. Subtle discomfort on manipulation just proximal to stifle. Stifle palpation largely unremarkable with some subtle uncertainty noted. Good ROM through stifle. L hind limb normal. No pain on DV palpation of spine.Integument: Coat is soft and clean, no ectoparasites detected, no obvious skin lesions or masses.Neurological: Normal mentation, no ataxia or CP deficits observed. Proprioception testing normal all limbs. Full exam not performed.Reproductive/Urogenital: External genitalia normal in appearance.Rectal: Not performedPROBLEM LIST:- R hind limb lameness- Overweight body conditionDIAGNOSTICS: None todayASSESSMENT:R hind limb lameness with subtle discomfort on manipulation proximal to stifle. Differentials include cruciate ligament strain/partial tear vs muscular strain vs lumbar spinal pain (radicular pain). No evidence of complete cruciate rupture on examination. Neurological examination unremarkable. Conservative management with rest and analgesia indicated. Monitor for progression of lameness or development of bilateral hind limb signs suggestive of spinal pathology. Stifle radiographs recommended if no improvement after 2 weeks strict rest or if lameness worsens. Weight loss recommended.MEDICATIONS:- Meloxicam - continue current dosing PO- Gabapentin - dose not specified, dispensed- Calming medication - dispensedPLAN:- 2 weeks strict rest (lead walks for toileting only, no play, no exercise)- Continue Meloxicam and Gabapentin for analgesia- Calming medication dispensed to assist with rest period- Monitor for development of bilateral hind limb signs or worsening lameness- Return immediately if signs of spinal involvement develop- Recheck in 2 weeks if no improvement or sooner if worsening- Stifle radiographs indicated if lameness persists after rest period or worsens - estimate to be emailed to O- Weight loss plan to be implemented- Contact clinic if additional Meloxicam needed    Vital Signs