C10020478 / invoice 10000

fish oilPatient Information:Milly McLevy, Canine, 11 years 4 months, FemaleDate of Examination: 12/03/2026Subjective:Presented for acute onset lameness in the left forelimb since this morningOwner reports the dog jumped onto the couch and "crashed". Since then, has been lame and not walking properly, appearing unsteady.Appetite is normal. No vomiting or diarrhoea reported. Water intake is normal. Urination and defecation are normal.No yelping or other signs of pain reported by the owner.Past medical history: Generally healthy, described as "bulletproof". No known medications. Receives fish oil supplements occasionally.Dietary history: Diet consists of Farmer's Market pouches (3 per week), homemade meals (meat, pasta, vegetables) twice a week, and half a roast chicken twice a week.Environmental history: Lives indoors. Owner is unable to walk the dog due to her own mobility issues. Dog is not walked regularly.Objective:Physical examination findings:General: Bright, alert, and responsive. Panting. Well-hydrated. friendlyMusculoskeletal: Limping on the left forelimb. Pain elicited on palpation of the left shoulder and elbow extension. Proprioception appears slightly delayed in the left forelimb compared to the right. No pain on palpation of the back. muscle wastage along spineCardiovascular: Heart NAD, no murmurs auscultated.Respiratory: Chest clear on auscultation, no crackles or wheezes.Abdominal: Soft, non-painful on palpation. No abnormalities palpated.Integumentary: Coat is in good condition. A previously noted lump on the left side is present but unchanged.Oral: mm pink and moist, moderate-marked tartar throughoutAssessment & Plan:1. Acute-on-chronic arthritis with soft tissue injuryAssessment: The clinical signs are consistent with an acute flare-up of underlying chronic arthritis in the left forelimb, likely involving the elbow and/or shoulder, precipitated by a minor trauma (fall). The underlying chronic arthritis is common for her age. Muscle wasting is also noted, likely secondary to reduced use of the limb due to arthritis.Recommended diagnostic tests: X-rays were discussed but declined by the owner at this time.Treatment plan:discussed NSAID vs gabapentin pros and cons. after discussion with o elected to go with NSAID. prescribed for 4 days for pain relief. Discussed long-term arthritis management options including joint supplements (e.g., green-lipped mussel), weight management, and Caltropan injections.Follow-up care: Re-evaluate if no improvement or if signs worsen. Monitor for any adverse effects from NSAID such as vomiting or diarrhoea. if no improvement consider sedated xray.    Vital Signs