C10019939 / invoice 10000

Reason: GAP *Back Right Limping, LameAppointment Notes: O can't see anything in paw, appears swollen HB*GAPONLYReason: Client Present:JesskaNurse:Back RIGHT leg. Jumped out of car approx. 2 days ago. Healthy Pets Wellness Testing: Done Yes / NoVaccination Type: UTDIntestinal worming: Bravecto UTDHeartworm Prevention: SR-12 UTDFlea Prevention: Bravecto UTDTick control: ^^^Microchip:Insurance and Healthy Pets Plus:Behaviour concerns:Current medications:NoCurrent Diet:Type of Shampoo/Frequency:Toileting: NAD__________________________________________________________________________HISTORY:Elvis presented for right hindlimb lameness. The owner reports that on Tuesday (10/03/2026), after urinating at the park, Elvis yelped and began hopping, holding the leg up. The lameness appeared to improve throughout the day. Yesterday (11/03/2026) at the beach, he was initially walking normally but then became subdued and stayed close to the owner, which is uncharacteristic. Owner thought there was possible swelling on the upper aspect of the right hindlimb when viewed from behind, but is uncertain, looks normal now. There are no visible wounds. Appetite and toileting are normal. Behaviour is reported as quieter than usual.UTD with vaccinations and preventatives at homeEXAMINATION:QARHR 102 RR 24 MM pink CRT <2secCV no murmurs or arrhythmias, strong femoral pulsesResp normal bronchovesicular soundsMSK ambulatory, grade 1/6 lameness RHL, occasionally toe-touching when standing. No swelling noted, no foreign material or wounds on paw pad, interdigital space. Hip and tarsus normal ROM on extension/flexion, unable to feel any cranial drawer R stifle today.Skin soft coatOpth clear eyes, normal pupilsLN submandibular LN NADDIFFERENTIAL DIAGNOSIS/DIAGNOSIS:- Soft tissue injury (e.g., muscle strain/sprain)- Cruciate ligament injury (partial or complete tear)- Insect bite/sting (less likely, no redness observed)**DIAGNOSTICS:**None**ASSESSMENT:**Lameness RHL - DDx soft tissue injury (muscle, tendon, possibly cruciate ligament injury), insect bite/sting (less likely as there is not redness/swelling noted anywhere), bone injury unlikely.Discussed with owner options - can trail course of anti-inflammatory medication with rest/confinement at home, see if lameness resolves. If not - then concerned for possible cruciate ligament injury/something else going on - need HL xrays. Owner agreed to plan. **TREATMENT:**- Meloxicam oral liquid 1.5mg/ml - Give 35kg dose once daily with food, for next 5 daysPLAN:The plan is to trial a course of anti-inflammatory medication and rest for the next 5 days. Re-evaluation is recommended if the lameness does not resolve or worsens, at which point further diagnostics such as radiographs would be considered. Owner advised to restrict activity, particularly over the weekend. To be discharged into owner's care.CLIENT COMMUNICATION:Discussed the differential diagnoses for the lameness, including soft tissue injury and cruciate ligament disease. Explained the treatment plan involving a trial of anti-inflammatory medication (Meloxicam) and strict rest. Advised that if the limping persists after the course of medication, further investigation, such as radiographs, would be necessary to rule out a ligament injury. Instructed on the administration of Meloxicam once daily with food for five days. Emphasised the need for restricted activity Estimate for HL xrays added to file just in case xrays are needed.Scripts Needed - Yes or NoRevisit needed - Yes or No - ____ Days pleaseReason: Nurse: -vaccination -heartworm -worming -flea/ticks Exam: Lab: Assessment: Treatment: Plan:    Vital Signs    Weight: 35;