C10008825 / invoice 10000

Presented for -  recheck right hock
acute onset lameness right hind 2 weeks ago during play in park
rads taken at PVE did not show any fracture

has improved a lot since initial injury but improvement has stagnated last few days
is not loving being confined to house
GI signs have completely resolved since stopping meloxicam

Current medications:  paracetamol 250mg bid, neurontin
Parasite control: 

Mentation: very bright
EDUF:  nad
Diet: 
MM:  pink
CRT:  imm
DS: 1/4
Skin tent:  nad
LN:  nad
Ears:  nad
Eyes:  nad
Thyroid: 
HR:  120
Chest Auscultation:  nad
Abdo Palpation:  soft relaxed
BCS: 5/9 
Temp: not assessed today
Rectal Exam:  nad externally
Skin: nad
Joints/Gait: 3/5 lame right hind - toe touching and taking some weight but also often non weight bearing
there is moderate bony callous formation rostral tarsus and some decrease in flexion of tarsal joint.  The area is comfortable to palpate and there is no palpable instability
Urogenital: nad
Vaccination status: current
 
Problem list:  ongoing lameness plus bony thickening tarsus
suspect healing fracture / severe contusion
neoplasia / infectious cause dim possibility
DDx:

Treatment in clinic:

Plan: continue rest, drop meds to paracetamol only

Communication: recheck 1 month - likely repeat xrays possibly with submit for radiologist interpretation

Rang O and advised Animalius were full (as per nurse task set for today) , however , this task must have been set prior to the follow up call from us because the O said Lucy is still improving and happy to watch wait and not go ahead with CT for now. I confirmed we can do so , and if she is concerned , or Lucy looks in pain again ,to call us and discuss and perhaps proceed with CT. JG

Animalius called, unable to see Lucy for consult + CT as no surgeon available. Have advised us we will need to seek other specialist for O. Task set for nurse to advise client. HB