C09983730 / invoice 10000

Hospital Day 2: Hip Dislocation 

Archie is ambulatory on his LPL, lameness at least 2/5. 

(AM)
S: BAR, unsettled/stressed -> noisy dog in ward with Archie
- Pain score: 2/24 -> quiet, unsettled
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COMMUNICATION:

(PM)
S:
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COMMUNICATION:

Updated on bill: (Y/N)
Name of owner:
Amount:

PRESENTATION: Hip Issues

HISTORY:
Walking through house, leg went out from under him - today < 1h ago. Vocalised. Left hind limb now sore and at a strange angle.
Going well on right, walked this morning, was running and jumping as normal.

Current medications: nil
Diet: 

PHYSICAL EXAMINATION:
Demeanour-QAR, FAS yellow, nervous but very good for exam.
Cardiovascular-MM pink, CRT 1 sec, P 124
Respiratory-RR 16
Neurological-nad
Musculoskeletal- left hind limb standing with stifle pronated and is longer than RHL/hock dropped compared to RHL. Palpation of CFJ - Luxation palpable, suspect medial and ventral rather than classic dorso-lateral.
Lymph Nodes-nad
Gastrointestinal-nad
Genitourinary-nad
Integument-nad
Oral-nad
Eyes-nad
Ears-nad
Rectal-ne

PHYSICAL EXAMINATION PROBLEM LIST:
-Left CFJ luxation

DIAGNOSTIC EXAMINATION:
Recommended radiographs and reduction, transferred to PDH. Did not place consult charge on invoice, is on estimate for all to go together for insurance.

PRESENTATION: C7 & Annual Health Check & Heartworm Prevention SR12

HISTORY:
Current medications: Nil
- doing really well, running full speed, on/off couch each night
- O reports far more happy and comfortable now, very happy with his recovery

EXAMINATION:
Demeanour- FAS green, BAR
Cardiovascular- nad
Respiratory- nad
Neurological- nad
Musculoskeletal- good comfort and ROM to R hip (post FHNE). Slightly reduced ROM to L hip. Some muscle assymetry (R msucle atrophy remains)
Lymph Nodes- nad
Gastrointestinal- nad
Genitourinary- nad
Integument- nad
Oral- nad
Eyes- nad
Ears- nad
Rectal- not performed

PROBLEM LIST:
Recovery post FHNE R - WNL

DIAGNOSTIC EXAMINATION:
HW test - no antigen detected, no micorfilaria. GK text O negative results after consult. 

ASSESSMENT:
Fit to vaccinate. Can not find in hisotyr (us or BPV) - history of SR12 last year - recommend HW test today and 6mths to be sure. 

TREATMENT:
C7 Sr12

PLAN:
6mth HW test (overdue today) - reminder set and explained to Mark reason for retest 6mths

RECOMMENDATIONS:
Continue exercise/wlaking/swimming within confines of hot weather lately

Next visit booked: (N)