C10013361 / invoice 10000

Reason: Sore  Leg.  SpAppointment Notes: Overdue remindersHISTORY:Harper presented for investigation of left hind limb lameness.The owner witnessed Harper on Saturday running while holding up the left hind leg. There have been two or three previous episodes before Saturday.Harper is otherwise well, with a good appetite and normal drinking habits.No vomiting or diarrhoea reported.Current meds: noneParasite Prevention: Not mentionedCurrent Diet: Advance Oodle dry food, less than half a cup per day, plus two treats. EXAMINATION:Demeanour/Behaviour: 4/4, BAROral: mm pink moist, good refill: - Grade 1 dental disease -mainly lower right arcade worse affected. Food stuck over the teeth..Appetite: goodLymph Nodes: None PalpableCardiovascular: cardiac auscultation normal, no murmur audibleRespiratory: thoracic auscultation clear, normal BV soundsGastrointestinal:- Abdominal: no detectable pain on abdominal palpation, comfortableMusculoskeletal: Palpation of left stifle - grade 1 medial luxating patella. - LH - no pain with luxation of patellar. - Right hind limb examination is unremarkable.- patellar seated in grooveSkin: Healthy coatEars: ClearEyes: No abnormalities detectedBody Condition Score: 7/9Hydration status (%): well hydratedTemperature: Not takenASSESSMENT:Grade 1 medial luxating patella, left hind limb. - no clinical pain. TREATMENT:No medications prescribed at this time.PLAN and CLIENT COMMUNICATION:Harper discharged into owner's care.Discussed the nature of a medial luxating patella, including the grading system and the commonality in small breed dogs.Advised on conservative management for a grade 1 luxating patella.Recommendations include weight loss and strict rest from jumping on/off furniture. The owner has already implemented steps for bed and couch access.Explained that if the leg is held up, gently extending it can help replace the patella.Advised on monitoring for signs of pain, such as reluctance to jump, go upstairs, or vocalisation on manipulation, which would necessitate re-evaluation for potential surgical intervention.The possibility of progression to a higher grade was discussed and will be monitored at annual health checks.A brief overview of the surgical procedure (tibial crest transposition, trochlear groove deepening) was provided when asked by the owner.The risk of cruciate ligament rupture with a luxating patella was mentioned as a worst-case scenario.Discussed dental health, noting Harper may require a professional dental clean in the future despite home care efforts.Re-check advised if lameness worsens or signs of pain develop.    Vital Signs