C09986704 / invoice 10000

Reason: Stifle xrays

Examination: Limited exam due to temperament. 
mm:pmg, CRT<2s.
HR 100 
Lame L back leg

Sedation:
Medetomidine 0.5ml / Butorphanol 0.5 ml iv. 
Reversal with Atipamezole 0.5 ml 
Worked well and recovery uneventful 

Imaging: Radiographs taken of his lumbar spine, hips, stifles and L tarsus. 
Subluxation of the hips evident on VD extended view.
Joint effusion L lateral stifle. 
Unable to elicit a cranial drawer sign. 

Assessment:Partial CCL rupture L hind leg
Bilateral Hip dysplasia

Treatment:Carprofen 100 mg BID. 

Plan:Exercise modification.
Referral to Specialist. 

Patient Information:
- Dog, 4 years old

Reason:
- Left hindlimb lameness when jumping

History:
- Crying when jumping, left hindlimb affected
- Cautious on stairs, not crying but still cautious
- Duration: couple of weeks
- Exercise restricted - stopped jumping/barrier work
- No current medications
- Last seen November for vaccine
- Weight trending up: 48.3kg -> 49.4kg -> 50.5kg today
- Sometimes fasting himself, eating unchanged

Examination:
Mentation: BAR
BCS (0-5): overweight, ribs not easily palpable
mm: pmg               CRT: <2s
HR: 80                 RR: normal
Ln: nad
Dental Grade: 2
Heart/lungs: NAD. Abdomen: tense, no detail
No spinal pain. No pain on exam of LHL. Resist hip exam and started growling.

Assessment:
1. Left hindlimb lameness
- No joint swelling or obvious abnormality on palpation
- Differential: knee or hip pathology
- Options discussed: anti-inflammatories and rest vs X-rays under sedation
- Owner elected for X-rays

2. Weight gain
- 2kg above ideal weight (target ~48kg)
- Metabolism slowing at 4 years of age
- Weight management advised

Treatment:
- Nil today

Plan:
- X-rays hips and knees under sedation tomorrow
- Drop off 08:20, NBM from tonight
- Pick up 3-6pm
- Estimate to be sent
- Weight management: reduce by 2kg, target 48kg

Reason: Vaccination

History:
BAR DUDE normal
Foot healed well
No other concerns reported
Gives simparica TRIO

Examination:
BAR, anxious++
HR 112, no murmur/arrhythmia
Panting, effort wnl, normal lung sounds
MM pink and moist
Abdo palp nsf
Eyes ears skin nsf

Assessment:
*Healthy to vaccinate

Vaccination given: C5- Protech C4 5257034b, 25/06/26 and injectable BB 15504, 06/26