C10009200 / invoice 10000

Reason: Lame Hind Leg ETA - 11:15am Appointment Notes: HS okedSubjective:- Left hindlimb lameness for approximately one week- Intermittent nature: some mornings running normally, other times non-weight bearing on affected limb- Episodes of three-legged running followed by weight placement- Owner reports improvement with rest, worsening with activity- Yelped when leg knocked this morning, became sulky and reluctant to move- Given meloxicam this morning by owner- History of climbing in rock gardens chasing lizards- Very active dog, loves running around and is very mobilePast Medical History:- Previous veterinary visits with sedation required (trazodone used)Objective:- Cannot facilitate physical exam today, tried biting owner and vet when restrained- Left hindlimb lameness observed 3/5. Still ambulating well - Weight bearing present but intermittent, standing on hind legs in consult- Physical examination limited due to patient temperament- No definitive cruciate palpation possible due to patient temperamentAssessment:- Suspected left cruciate ligament injury (potential partial tear), due to presentation and history. However advised O cannot rule out other causes without further diagnostics- Differential includes muscle strain or other soft tissue/orthopedic injuryPlan:- Meloxicam for pain relief (proper dosing to be provided)- Gabapentin for sedation and additional pain relief- Strict cage rest for minimum two weeks, Lead walks only for toileting- Monitor progress over next 1-2 weeks- Return if no improvement for further investigation including sedation and radiographs- Surgical option available if conservative management fails    Vital Signs    Weight: 7;