C10000751 / invoice 10000

R hindlimb lameness - 7/3/26

Subjective:
Seen for :
- owner reports acute right hindlimb lameness since last night. had been outside in backyard playing with the kids and chasing toys. was running and jumping from deck onto grass (approx 25cm height). no injuries noted at the time, no falls, no yelping. no accidental standing on her. then ran upstairs normally to eat dinner but progressively starting limping more and more on right hindlimb over the next few hours until non weight-bearing lame
- owner took to AES last night where she received methadone and gabapentin
- slept more comfortably after this
- no improvement in lameness this morning - will toe-touch but not weight bear
- still BAR, good appetite, no vomiting or diarrhoea, normal thirst and urination
- current meds: gabapentin 100mg PO BID, last given last night

Objective:
T 38.5, PR 112, RR , MM pink, CRT <2s
Body condition: 5/9
Thoracic auscultation: No murmur or arrythmia, respiratory rate and effort WNLs, no adventitial sounds.
Abdominal palpation: Soft and non-painful, no distension or fluid wave
Eyes: Clear, no discharge. Pupils even with normal PLRs and menace.
Ears: Clean with no discharge or erythema.
Mouth: Grade 1 calculus, grade 1 gingivitis
Integument: Healthy haircoat, no lesions or masses
Musculoskeletal: toe touching lame right hindlimb. normal ROM all joints but very painful on extension of stifle. hips palpate normally. no swellings or crepitus palpable. no joint effusions palpable. no signs of wounds or cellulitis. no neck or back pain
Neurological: BAR, cranial nerves WNLs
Rectal exam: Not performed

Assessment:
- grade 5/5 right hindlimb lameness - pain localised to stifle (particularly extension)

Differential diagnoses:
open - soft tissue injury, fracture, tibial avulsion, growth plate injury, septic arthritis, other

Plan:
- admit for pain relief & radiographs
- gave 0.3mg/kg methadone SQ. adequate to facilitate taking radiographs
- radiographs taken: L + R lateral hindlimb, L + R CC stifle, VD hips
    - main findings are severe joint effusion R stifle. no sign of fracture or growth plate injury. no evidence of OCD lesion on CC. tibial crests identical on L and R stifles
- revised DDx soft tissue injury, cruciate injury, can't rule out growth plate injury
- home on STRICT CONFINEMENT (crate rest) 14 days. continue gabapentin 100mg PO BID and add in meloxicam 0.1mg/kg PO SID 7 days
- KEL will email xrays to specialist for second opinion
- septic arthritis unlikely as normothermic, no overlying wounds or redness and no systemic signs, but if not improving recommend repeat rads PLUS arthrocentesis and C&S of joint fluid

after 8am - morning preferred
2nd puppy vax

call - 0417 104 383 (Corey)

Vaccination -

Subjective:
Seen for vaccination

- EDDU normally, no V/D
- no current medications
- prophylaxis- was given something with the breeder but O can't find paperwork to confirm product, O has not given any parasite prevention since being in their care
- BAR on examination
- O concerned re possible lump on R body wall
- O enquired re heartworm injection as would prefer to have Cookie on proheat, bravecto and intestinal wormer q3m

Objective:
Sweet angel, very confident with todays visit
T , PR 120, RR 24, MM pink, CRT <2s
Body condition: 5/9
Thoracic auscultation: No murmur or arrythmia, respiratory rate and effort WNLs, no adventitial sounds.
Abdominal palpation: Soft and non-painful, no distension or fluid wave
Eyes: Clear, no discharge. Pupils even with normal PLRs and menace.
Ears: Clean with no discharge or erythema.
Mouth: deciduous dentition with normal occlusion
Integument: Healthy haircoat, no lesions or masses. 13th rib palpates more prominent on RHS compared to LHS. No pain or masses palpable.
Musculoskeletal: Ambulatory with no lameness
Neurological: BAR, cranial nerves WNLs
Rectal exam: Not performed

Assessment:
Due for vaccination

Plan:
- vaccinated protech C3 SC + KC intranasal + NGS PO
- Final puppy vax 4 weeks + can commence heartworm injection at 16 weeks, repeat again in 6 months and then annually vs can continue NGS until first adult vaccination and commence heartworm at that appointment. O leaning toward continuing NGS until fully grown. Please confirm at next appointment.
- Please repalpate R body wall at next vaccination

Consultation - Check up and nails

Subjective:
Cookie is a 10wk FE American Pocket Bully who is being seen for a new pet health check. O bought Cookie from the breeder ~1 week ago, and reports she is settling in well. Cookie is the only pet at home, O had a staffy that passed away a year or two ago. O is planning on insuring Cookie, and she is starting puppy school in a few days!

- EDDU normally, no V/D
- no current medications
- BAR on examination

Objective:
Demeanour: nervous when we arrived, barking at us but settled quickly
T not taken, PR 136, RR 32, MM pink, CRT <2s
Body condition: 4/9
Thoracic auscultation: No murmur or arrythmia, respiratory rate and effort WNLs, no adventitial sounds.
Abdominal palpation: Soft and non-painful, no distension or fluid wave, no umbilical or inguinal hernias. 
Eyes: Clear, no discharge. Pupils even with normal PLRs and menace.
Ears: Clean with no discharge or erythema.
Mouth: Grade 0 calculus, grade 0 gingivitis, deciduous dentition, normal occlusion
Integument: Healthy haircoat, no lesions or masses
Musculoskeletal: Ambulatory with no lameness
Neurological: BAR, cranial nerves WNLs
Rectal exam: Not performed

Assessment:
1. Puppy health check - healthy puppy with no concerns on examination today!
2. Nervous on arrival - need to ensure upcoming vet visits are positive to ensure Cookie has a nice experience each time :)

Plan:
- nails trimmed
- 2nd puppy vax booked for 24/2 
- recommend NGS or Simparica Trio for parasite prevention