C10021220 / invoice 10000

12/03/2026 NURSE: MY

REASON: RF lameness, started 4 days ago.

HISTORY:
- Limping on RF leg since Monday, not wanting to put pressure on it.
- Today, refused to move, requiring carrying.
- No known trauma.
- Previous episode of sore leg after kennelling, resolved with anti-inflammatory.
- No licking of the foot, no reaction to palpation at home.

ACTIVITY: Very energetic, described as a "jumping lunatic". Difficult to contain.

CLINICIAL EXAM:
- Mentation: BAR
- MM: Pink, moist
- Oral and Dental Score: Grade 0-1 teeth.
- Eyes: Clear.
- Ears: Clean and clear.
- BCS: 3/5
- HR: 120 bpm.
- MSK: Lameness on RF leg. No consistent pain on palpation of joints (digits, wrist, elbow, knee). Questionable pain on flexion of shoulder, but inconsistent. Reacted to palpation of upper forearm muscles.
- Skin: No abnormalities noted.

ASSESSMENT:
- Suspected soft tissue injury, likely muscle strain in upper forearm.
- No evidence of bone or joint issues.
- X-rays not indicated at this stage.

DISCUSSION:
- Discussed likely soft tissue injury.
- Explained need for rest and pain relief.
- Advised on strict rest for 1 week: confined to a room, lead-only for toileting.
- Discussed use of Trazodone for sedation if needed.
- Advised to stop anti-inflammatory if vomiting or diarrhoea occurs.
- Discussed upcoming dog trial on weekend; advised it may be okay if on lead and he is improving.

TREATMENT:
- Anti-inflammatory pain relief medication dispensed.
- Trazodone dispensed for sedation, 1 tablet BID. Can reduce to 3/4 tablet if too groggy.

PLAN:
- Strict rest for 1 week.
- Administer anti-inflammatory and Trazodone as directed.
- Monitor for improvement over the next week.
- Recheck if no improvement or if lameness worsens.
- X-rays are a plan B if no improvement.