C10016423 / invoice 10000

Weight (Kg):9.00
History:History: O presents 5y M Moodle for a general checkup. Primary concerns include an intermittent left hindlimb skipping lameness noted for ~2 weeks, a perceived swelling on the hard palate, and a noise made when his neck is touched. History of atopy managed with Cytopoint injections. EDDU normally. No V+/D+. No coughing/sneezing.

Physical Examination:

- BAR
- Eyes & ears clear, free from discharge or inflammation.
- Oral Exam: Mild tartar accumulation. No significant gingivitis. Palpated structure on hard palate is normal anatomy- small raised portion at meeting of hard palpate at cranial portion of mouth- behind upper incisors.
- MM pink & moist, CRT <2, no skin tent.
- Cardiothoracic auscultation clear with no murmurs/arrythmias, crackles or wheezes. Pulses strong & synchronous.
- Abdominal palpation soft & comfortable with no palpable masses, organomegaly or thickenings.
- Musculoskeletal: Grade 1/4 medial patellar luxation, left stifle.
- No peripheral lymphadenopathy
- Skin & coat in good condition
- Weight: 9.0 kg

Differentials:

- Left hindlimb lameness: Grade 1 medial patellar luxation vs. soft tissue injury?

Treatment:

- Cytopoint injection administered for pruritus.
- to be given 1/2 tablet PO SID PRN for lameness.

Recommendations & Follow Up/Discussion:

- O reassured that the oral structure is normal anatomy.
- Monitor frequency of left hindlimb lameness. Administer dispensed anti-inflammatory on days when lame. Recheck if lameness progresses for further investigation, including potential radiographs.
- Continue dental home care (brushing, water additives). A professional dental cleaning is recommended in ~1 year.
- Weight loss was discussed and recommended.

LOG