C09999285 / invoice 10000

05/03/2026 DATE/TIME of CONSULTATION: 21:55hrs, Thu 05/03/26
CLINICIAN: Alycia Tsiang 
PRESENTING COMPLAINT: Possible fracture 

HISTORY:
Couple weeks ago started limping on LFL. Went to reg vet - NSF on radiographs. Home with NSAIDs and rested 14 days
Was fine the day after. Ceased medication as back to normal
3 days ago this has recurred, holding LFL up and limping. Stopped eating today, seems lethargic, unable to settle. O restarted carprofen but no improvement. Not putting any weight on it. 
No known incidents. 
No other health issues. 

CLINICAL FINDINGS: 
BAR
Non-weight bearing on LFL, lame 5/5 
Oral exam MM pink, CRT <2s
Thoracic ausc HR 100bpm no m/a. Increased BV sounds consistent with panting, upper resp sounds 
Abdo palp soft & comfortable
Integument - no wounds noted, healthy coat
Temp 38.9
LN small & symmetrical 
Comfortable on extension/flexion of shoulder, elbow and carpus. No pain elicited on palpation of long bones. Squeals/cries on palpation of digit 3, mild swelling over metacarpal area. 

PROBLEM LIST:
LFL lameness, pain on digit 3

DIFFERENTIALS:
Digit 3 fracture, soft tissue, grass seed abscess, trauma

OPTIONS PROVIDED:
1. Admit for radiographs
2. Analgesia until sx appt booked (in 6 days)
O elected option 2

DIAGNOSTIC TESTS:
nil performed

DIAGNOSIS:
Open 

TREATMENT:
Bup 0.01mg/kg SC

CLIENT COMMUNICATION/PLAN:
O to continue carprofen as dispensed by reg vet. 
Rx pregabalin 25mg PO BID, strict rest until sx appt
R/v if swelling increases, pain not well managed