C09992452 / invoice 10000

  HISTORYPresenting for: Canine patient, a 2.5-year-old female presented for leptospirosis booster vaccination and recheck of right hind limb (RHL) lameness previously assessed last month.Historical Conditions:- Assessed last month; hip dysplasia/hip pathology or ACL damage suspected at that visit- RHL lameness noted at previous visit; anti-inflammatory medication dispensed at that timeLifestyle Risk Factors:- Walked on leash; client reports allowing off-leash running briefly (~5 min) during walk home, after which lameness recurred the following dayOther:- Client reports lameness improved on anti-inflammatories during the ~3-week period away- Following return and brief off-leash running, lameness recurred the next day- Client observes: swinging gait at the hips, bunny-hopping (using both hind limbs together when running), and sitting to one side - client attributes these signs to a hip problem based on online research- Client notes patient is good at masking lameness; will rest for a couple of days when limping then return to running/spinning in the yardEXAMMusculoskeletal: RHL lameness noted on observation as patient entered clinic. Orthopaedic examination performed. Hip joints: range of motion assessed bilaterally (flexion and extension); no significant pain response elicited on hip manipulation either side. Stifle joints: pain response (withdrawal reaction) elicited on cranio-caudal manipulation of the right stifle, raising concern for stifle pathology as primary issue. Drawer sign assessment attempted; no definitive instability detected, though patient is large and muscular with significant resistance, making assessment unreliable without sedation. RHL lameness with suspected stifle pathology - DDx: cranial cruciate ligament (CCL) sprain vs. partial or complete rupture; concurrent hip dysplasia or hip arthritis cannot be excluded. Pain response localised to stifle on orthopaedic exam. Definitive assessment not possible without sedation; drawer sign inconclusive due to patient size and muscle mass. Hip pathology remains a differential given signalment and previously noted clinical signs.PLANVaccinations:- Leptospirosis booster administered; subcutaneous injection. Client advised injection site may be mildly pruritic shortly after administration.Diagnostics:- Sedated orthopaedic examination under general anaesthetic recommended: thorough palpation of hip and stifle joints bilaterally, including drawer sign assessment, plus radiographs of hips and stifles- To be booked as a drop-off appointment; reception to schedule next week (or sooner if cancellation available) 

HISTORYPresenting for: April, a canine patient, presented for vaccinations and assessment of a sore right hind leg.Historical Conditions: Intermittent right hind limb lameness for approximately 2 months, worse after exercise but recovering quicker nowDiet: Normal appetiteDrinking/Urination: NormalCurrent Meds: Symiotic drink for parasite preventionLifestyle Risk Factors: Access to fields for exerciseOther: Owner reports patient drinks from puddles when thirstyEXAMMentation: BARWt:BCS:T: Not TakenHR:R:MM:Hydration:Behavioural:Eyes:Ears:Nose:Throat:Oral:Cardiovascular:Respiratory:Abdominal:Lymph Nodes:Integumentary:Neurologic:Musculoskeletal: Non-weight bearing on right hind limb. Patient shifts weight to left hind limb, placing it toward midline of body. Mild cranial drawer movement detected in right stifle. Pain on hip manipulation of right hind limb.Urogenital:Rectal:Diagnostics:ASSESSMENTRight hind limb lameness - DDx: partial cranial cruciate ligament tear, hip pathologyPLANVaccinations:- Canine Core vaccine administered today- Leptospirosis vaccination discussed and approved. First dose administered today, second dose due in 4 weeks (Feb 19-26)- Discussed Leptospirosis risk factors including drinking from puddles and exposure to rodent urineNew Meds/Tx:- Anti-inflammatory medication dispensed for 7 days. Rest advised with leash walks only, no off-leash activityAdditional Discussion:- If lameness persists after 1 week of rest and anti-inflammatories, radiographs of hip and stifle recommended- Discussed possible surgical intervention if cruciate ligament tear is confirmed- If hip pathology is diagnosed, likely to require management rather than surgeryClient Comms:- Recheck in 1 week if no improvement- Client traveling for 3 weeks, returning February 19- Leptospirosis booster to be scheduled upon return

Examination Text:Reason: VaccinationAppointment Notes: No other health concerns stated over phone.History: On simparica trioBeen wellExamine: Good condition, a bit boistrous but good naturedEyes/ outh ears cleanChest clearTreatment: Bronchishield Bb oralDuramune C3 and Protech Pi2 scPlan: Kc next yearJoin dog club for socialisation