C09984100 / invoice 10000

WEIGHT: 18.50

WEIGHT: 15.6
HISTORY: 15 Feb 2026 08:12:53 am EXF


Client consented to use of dictation software
Reason for presentation: Limping and non-weight bearing on a hind limb after playing yesterday.

History: The patient is a six-month-old female entire Brittany Spaniel. An incident occurred at approximately 4:00 PM yesterday during play, resulting in a yelp and subsequent non-weight bearing lameness. The patient has been crate-rested since the incident. The owner notes significant swelling of the R  tarsus. There is a known history of high tendon elasticity dx at wollongabba GX , and previous radiographs have confirmed good hip conformation despite a splayed sitting posture. Eating and drinking are normal. Urination is normal. Faeces are slightly constipated on rectal examination.

Medications: Up to date with worming and tick prevention. Vaccinations are current.

Clinical examination:
Mentation: Bright, alert, and responsive.
MM/CRT: Pink, moist mucous membranes. Capillary refill time is less than two seconds.
CV: 96 No murmurs or arrhythmias auscultated, femoral s+s
R: 16 clear bronchovesicular sounds 4/4 field, normal pattern and effort
Dental: 1/4
PLNs (submandibular, pre-scapular and popliteal): soft, small, symmetrical
Eyes: Clear OU, pupils symmetrical and tracking - no swelling, discharge, erythema, hyperaemia or blepharospasm
Ears: no erythema malodor or discharge 
Abdomen: Soft and non-painful on palpation, no palpable organomegaly
Skin:  clean, lovely coat free of visible ectoparasites
Temperature: 38.8
Rectal examination: n/p
MSK: Non-weight bearing on RHL hind limb. Significant swelling of the tarsus, approximately double the size of the contralateral tarsus. Rest of joints are non-painful and free of crepitus with good ROMs 
Neuro: appropriate, withdrawel present 4/4, normal posturals (roughly assess on NWBL RHL due to pain)
Urogenital: FE not had a season yet, No abnormal swelling, discharge or erythema of the vulva
BCS: 4/9 

Problem list:
Acute onset non-weight bearing lameness of a hind limb 4pm 14/2/26
Marked swelling of the R tarsal joint.

Differentials:
F# vs soft tissue 

Client communications:
Discussed the significant swelling around the tarsus. Explained that if a small fracture is present, this would likely require referral to an orthopaedic specialist as the tarsus is a complex joint.

Treatment/plan:
Admit for sedation and radiographs of the tarsus to investigate for effusion, fractures, or cruciate ligament injury.
Provide analgesia, including methadone.
Discussed that further management will depend on radiographic findings.
Paperwork signed for admission and imaging.


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administered 5ug/kg medetomdine and 0.2mg/kg methone IV for radiographs. Topped up with 5ug/kg medetomidine to facilitate DP views. 
Smooth sedation and IM reversal with 0.14mls antipam IM. 
Splinted modified RJ placed on R Tarsus.
50Ug/hr fentanyl patch (1/4 of patch not in contact w/skin) placed on the left HL. Active at 21:30 15/2/26
Metacam sc 0.2mg/kg administered 11am. 

Rads confirmed f# of the distal aspect of the R calcaneus possibly with growth plate invovelemt (due to age)

Discussed with O recc refferral to QVS as Wollongabba GX only dor Orthopaedic sx on 12kg and under. - adv may be around or over 10k at refferall P is insured. 

Discharge at 6:30pm after final dose of methone before arranging referral with QVS team tomorrow.