C10019106 / invoice 10000

12/03/2026 NURSE: AM

REASON: Limping

HISTORY:
- Noticed slight limp 2/7 ago. RFL ginger. Yesterday NWB. Started placing last night, weight bearing this morning.
- Much improved. Has done this before and it resolves.
- Gets Synovian inj.
- R shoulder always slower to recover.
- OCD lesions bilaterally - diagnosed with arthroscope in shoulders and elbows.
- No HL issues.
- Gave 3/4 Panadol last night.

APPETITE: Normal.
ACTIVITY: Spirits fine. Keen to walk.
DIET: Lost 3kg with food change.

CLINICIAL EXAM:
- Mentation: BAR
- MM: Not assessed
- CRT: Not assessed
- Oral and Dental Score: Not assessed
- Eyes: Not assessed
- Ears: Not assessed
- BCS: Not assessed
- Lumps: Not assessed
- Abdominal: Comfortable.
- Lymph nodes: Not assessed
- HR: 76bpm, normal sounds and rhythms.
- RR: 20rpm, clear chest sounds.
- Temp: 38.5°C
- Urogenital: Not assessed
- MSK: LFL - comfortable in shoulder, reduced ROM in elbow. RFL - discomfort and decreased ROM in elbow, shoulder OK.
- Skin: Not assessed

ASSESSMENT:
- Likely inflammatory flare. Cannot rule out bone fragment or infection - these often more painful and wouldn't improve this quickly.

DISCUSSION:
- Discussed may have overdone it.
- If persisting will need another scope.

TREATMENT:
- Anti-inflammatory dispensed (not Meloxicam - causes GI upset).
- 1 tab PO SID, 1 hour before food.

PLAN:
- Rest for 7 days.
- No walks, ball throwing or strenuous activity.
- Swimming in water OK.
- Recheck in 7 days.
- Watch for vomiting, diarrhoea, or change in eating.