C09987417 / invoice 10000

Reason: Front Left Paw ConcernAppointment Notes: Non-weight bearing after waking up in the mornings but better after "warming up" - still playing and going for walks.HISTORY:  - C/O lameness right forelimb.- Started 2 days ago.- Worse upon waking.- Improves with time/movement.- O suspects stiffness or injury from jumping on a person- Vaccinated 1 week ago.- Was well at vaccination. Current meds: noneVaccination: UTD.Parasite Prevention: Not mentionedPre-existing conditions: noneAccess to toxins eg. Rodenticide: none EXAMINATION:Body Condition Score: 5/9Pain Scale (0-4): 0/4Hydration status (%): hydration clinically adequateCardiovascular: hr 100 cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory:thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological:neurologically no significant findingsMusculoskeletal: Grade 1 intermittent lameness on LFL with head bobbing on RFL gait. Mild reaction on LFL shoulderGastrointestinal:- Oral: normal, no mouth pain, dental score (1-4):not graded- Abdominal: no detectable pain on abdominal palpation- Rectal: not performedUrinary: NSFReproductive: NSFIntegument/Ears: NSFLymph Nodes: NSFEyes: NSFDemeanour/Behaviour: not discussed PROBLEM LIST:- Intermittent LFL lameness. DIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:- Soft tissue injury vs shoulder joint arthropathy vs others DIAGNOSTICS:None ASSESSMENT:  - Presented for a 2-day history of right forelimb lameness, which is worse after rest.- Examination today revealed very mild LFL shoulder reaction, suspect mild soft tissue sprain/strain vs shoulder arthropathy such as OA/dysplasia vs others- Treatment trial commence and is adequate with NSAIDs to assess response at this stage TREATMENT:  - Meloxicam 10ml in 1.5mg/ml. 15kg dose PO SID for 5-7 days PLAN:-  rest for 1 week.- Monitor for any worsening of signs, may require MSK rads to re-.- Home into owner's care. CLIENT COMMUNICATION:- Discussed likely cause is a minor sprain.- Advised strict rest and monitoring.- Instructed to return if lameness persists or worsens.- No charges for this quick check.--- 03/03/2026 13:56:59 PM JES:Examinations - Resolved - Whisley doing well. EDUD all ok. doing well with medication. NIL further concerns. Will pin on schedule for vet to complete notes and for nurse to send for gaponly claim. MB    Vital Signs