C09993714 / invoice 10000

HISTORY: Charlie is presenting for progressive RH limb lameness over approximately 3 months.
Onset: Owner reports hind limb issue started intermittently and has progressively worsened over about 3 months; initially occasional, now more frequent. Seems worse after lying down for a long time and after jumping down from a height the day prior. Owner reports difficulty with back legs, predominantly the right, with progressive lameness over ~3 months. No sustained non-weight bearing recently. Seems stiff on rising after prolonged rest. Worsened after jumping down from a height the day before one flare. Household has concrete floors and steps.
Owner notes long-standing conformational issue in front legs since adoption.
Lifestyle Information: Rescue dog obtained at approximately 4 years old. Lives with 2 children and no other pets.
EDDU normal, no CSVD.
Diet: Scratch brand diet
Flea/tick/intestinal worming prevention: NexGard Spectra UTD
 
Physical Exam:

General Appearance & Behavior: Alert and food-motivated during exam.
Hydration Status: Oral mucous membranes pink.
Eyes: NSF, clear and free of discharge, pupils normal size, globes symmetrical OU
Ears: NSF, no discharge observed, no erythema present AU
Oral Cavity: Generalized dental calculus, more pronounced on caudal teeth; mild calculus on incisors. Gingival colour pink.
Nasal Cavity: NSF, no nasal discharge noted
Integument: NSF, skin appears normal; hair coat in good condition, no ectoparasites or masses noted
Lymph nodes: NSF, no peripheral lymphadenopathy noted
Thyroid: NSF, no enlargement or painful palpation noted
Cardiovascular: Heart auscultation subjectively normal per examiner comments; no abnormal sounds described.
Respiratory: No abnormal respiratory sounds described on auscultation during exam.
Abdomen: Abdomen palpates soft and non-painful.
Urogenital: NSF, no discharge noted. No abnormalities notes on bladder or kidney palpation
Musculoskeletal: Pain on extension of both coxofemoral joints during manipulation. Increased resistance to flexion of the right stifle compared to the left. No palpable joint effusion detected in stifles. Patellae assessed and sides felt similar. Intermittent non-weight-bearing on the right pelvic limb observed during the visit.
Neurologic: NSF, normal mentation, no obvious deficits notes, full neuro exam not performed
Rectal: Rectal exam not performed
Additional Notes: Sedation noted as potentially useful for more accurate orthopedic assessment due to conscious muscle tension.

Assessments:

Problem List:
Right pelvic limb lameness r/o CCL injury vs soft tissue strain
Bilateral hip discomfort on extension
Dental calculus

Plan:

Owner Discussion:
Reviewed diagnostic pathway: sedation radiographs of both pelvic limbs to assess stifles and hips
Outlined conservative management trial: strict rest with minimal activity (toilet breaks only) and a course of a non-steroidal anti-inflammatory (NSAID) for 7 days to assess response. If improvement occurs, consider continued pain relief if needed and gradual return to activity. If no improvement, proceed with radiographs.
Discussed potential adjunct analgesia with paracetamol (Panadol) if NSAID monotherapy insufficient; dose provided if needed.
Discussed dental findings and recommendation for professional dental cleaning within the next 3 months to address calculus and reduce risk of periodontal disease progression.
Recommended starting a daily joint supplement as preventative support, especially for front limbs. Provided product options: 4Cyte, Antinol, and Glyde

Owner elected to trial NSAID and rest first; to schedule if no improvement

Medications: 
Meloxicam: Please give 0.8mls ONCE DAILY by mouth WITH FOOD for 7 days then come back for recheck.
If any vomiting or diarrhoea occur or your animal stops eating normally stop giving this medication and contact the clinic. SHAKE BEFORE USE
WEIGHT: 11.70
WRMRQ: N
FLRQ: N