C09986942 / invoice 10000

NOTES: Admitted for 
Other pets at home:
Preventatives:
Last vacc: 
Previous vet where last vaccinated (inform reception):
Intestinal worming:
Heartworm prevention:
Flea and tick prevention:
Meds:

Pre-examinaton: BAR, omm pink and moist, CRT<2sec. HR and rhythm WNL, femoral pulses synchronous and normokinetic. Eupnoic
Pre-GA blood test results: WNL

Placed IV cannula and admin'd IVFT at maint/water available
Gave 0.2mL medetomidine and 0.2mL butorphanol IV
Gave oxygen per mask and monitored Spo2, RR and character, HR, pulses etc.
Procedure: 
Gave same volume of antisedan IM (dogs), Gave 1/2 volume antiseden IM (cats)
Recovery uneventful
Continued IVFT until discharge

NOTES: GapOnly Claim Insurance Summary

First Clinic Signs: Ongoing

Summary: 
Lameness that recurs despite rest and nsaids 

Diagnosis: 
LFL digit 2 sesamoid injury identified on radiographs

Treatment: 
Meloxicam and strict crate rest for 6 weeks

HISTORY: HISTORY
27 Feb 2026 03:27:47 pm NN Andre here with Zeus
Lameness has always been left fore (not shifting) - in the morning and at night only. Dog is fine during the day.
Treated initially with meloxicam for 7 days and lameness resolved (Dec 2025)
Dog became lame again 7 days after finishing melolxicam, seen 2 weeks later and treated with meloxicam for 2 weeks. Owner was advised to crate rest dog but he only did this for 2 days due to family pressures etc.
Stopped meloxicam about 6 weeks ago and puppy has been lame left fore since then.

Exam: 
Relaxed pup, walking normally in reception - no lameness
Gave treats during exam
Possible firm swelling over the dorsal aspect of 2nd MTP joint left fore. Puppy not sensitive with firm palpation here.
Reactive to palpation of digit 3 left fore as previously but equally reactive to palpation of digit 3 right fore.
Definitely no reaction to very hard extension of the left elbow or robust manipulation of the left shoulder
Not reactive to flexion of the interphalangeal joints in the hind paws or right fore
Pup cried with flexion of the interphalangeal joints left fore during flexion test outside.

Flexion test: no lameness elicited with shoulder, elbow, carpus or interphalangeal joint flexion tests (holding for 1min)
Advised comparative paw rads under sedation est $1230 with Gibbo's interpretation (verbal - forgot to include in dx plan). Owner booked in but will discuss with wife before confirming.

Meanwhile strict cage rest and 1.7mL meloxicam sid, can double dose tonight only.
WEIGHT: 26.10