C09994688 / invoice 10000

Reason: C/uAppointment Notes: ------- Sms reply: YesPATIENT:LunaFrench BulldogWeight:Reason: Recheck right hind limb lamenessHistory:Luna is a French Bulldog presented today for recheck to monitor right hind limb lameness. The owner reports putting more weight on the limb over the last two days. Previously was non-weight bearing on the right hind limb. Suspected ligament or muscle injury.Current medications: Gabapentin one dailyExamination:Vitals:Physical Exam:    - Musculoskeletal: Right stifle examined. Previous findings noted - coxofemoral changes on right side, possible stifle involvement. Rachel noted effusion on right stifle; Andrew unable to visualise effusion on imaging review.ASSESSMENT:Right hind limb lameness - suspected stifle pathology. Andrew does not believe hip is the primary problem. If cruciate ligament is intact, patella will be addressed; if cruciate ligament is partially torn, this will also be repaired.PLAN:Diagnostic/Treatment Plan: Continue gabapentin one in the morning and one at night. Rest and pain relief if limping recurs. If no improvement with conservative management, will proceed directly to surgical exploration of right stifle with Richard - will assess cruciate ligament integrity and address patella +/- cruciate repair as indicated. No repeat imaging planned prior to surgery.Recommendations: Monitor for recurrence of lameness. Continue restricted activity.    Vital Signs