C10023932 / invoice 10000

Reason: Lame Hind LegAppointment Notes: LOHistory:There is a history of a transient lameness episode when younger, which resolved within minutes. Suden onselt lameness this morning from 0900H. No known trauma, bite, incident etc. Objective:- General demeanour: Presented as bright and alert during the consultation, though the owner reported he was lethargic and refused to move for most of the day.NSF in pad- Musculoskeletal: There is marked favouring of the left hindlimb. Palpation of the left foot, ankle, and knee revealed no obvious abnormalities. The cruciate ligament appears stable. There is a possible mild pain response on hip extension. No swelling, crepitus, or displacement was detected on palpation of the limb.- Gait: Refusing to walk for most of the day. Toe-touching in consultAssessment:- Acute left hindlimb lameness: The primary differential diagnosis is a soft tissue injury, such as a strain or sprain, given the acute onset in a hyperactive animal and the absence of palpable orthopaedic abnormalities. A minor joint injury, such as jarring of the hip, is also possible.- Inappetence: Likely secondary to pain, as there are no other clinical signs such as vomiting or diarrhoea.Plan:- Administer a non-steroidal anti-inflammatory injection (meloxicam) in the clinic, as he has not eaten and cannot be given oral medication on an empty stomach.- Dispense oral pain relief to be administered at home.- Re-evaluate if the lameness and inappetence do not improve by tomorrow.- Consider radiographs of the hip and limb if there is no improvement, although it was discussed that these may not yield a definitive diagnosis for a soft tissue injury.Client communication:Discussed the likely cause of the lameness being a soft tissue injury given the examination findings. Explained that while radiographs are an option, they may not be conclusive and would not change the immediate management plan. Advised the owner to monitor for improvement overnight and to return for further investigation, including potential radiographs, if Teddy is not better tomorrowTreatment: Meloxicam 0.1mg/kg SID    Vital Signs