C10024252 / invoice 10000

Reason: L4  - UWR - Stumbling/limpingPresented and seen by Dr  JDA   @ 12.3 8pmRegular Vet: brimbank VCPresenting Problem: Acute lamenessHistory:O returned home this PM to find Bauer on grass, not moving, struggling to stand up.Last seen as normal this morning.Not known to have exerted himself or otherwise during this time but unkonwn.No V+/D+No likely toxic accessAny current medications: nilE/D/U/D: YesAny known conditions: NilPreventatives up to date? YExamination Findings:General demeanour: BARTemperature: 38.2Cardiovascular: HR: 124bpm, no murmur, MM pk/moist, CRT 1s. SSFPRespiratory: panting, normla effort, normla BVS on auscOral exam: NSFAbdomen: NSF, tense, no overt pain, no nausea on palpation (unable to feel effectively for mass effect)Peripheral LNs: WNLEyes/Ears: NSFIntegument: NSFMusculoskeletal: Sitfle pain (flexion) repeatable but stoic so difficult to get reaction. Very mild cranial drawer appreciable. No tibial thrust appreicable. No medial butress. Good ROM in hips, no pain/crepitus.Gait: LHL mild lameness, sitting with LHL outstretched mostly (however intermittently seen doing this with RHL too).Neurological: NSF, withdrawals as normal, CP as normal. Pain difficult to localise/repeatRectal exam: DNPUrogenital: NSFBody Condition Score: 5/9Initial Assessment:MIld lameness LHLStifle pain on flexion Ddx: Cranial cruciate dz/meniscal tear > sot tissue injury > spinal (G1)/otherClient Communication:Discussed concern for stifle lesion but inconclusive given lack of laxity palpatedIn any case is mild lameness as he is geting up and moving around relatively comfortably cf what was described when first noted lameness.Options:1) monitor at home over next 24-72hrs with melxociam PO - if appears increasingly painful/lame or other concerns in this time, recommend revisit for reasess and planned radiography of affected area (vs CT).2) admit to hopstial for radiogpahy of LHL (stifle, hip/pelvis)O elects option 1 -> to return (RV/ARH) if ongoing concerns of lameness and no improvemnt.Current problems: Mild LHL lamenessPrognosis: GoodTreatment: Meloxicam for next 5-7 days, SID 0.1mg/kg POPlan:Monitor pain, gait, ambulation, EDDU over next 1-3 days. If concern for no improvement or deterioration in this time -> reccommend revisit (ARH/brimbank) for assesmsent and likely radiography .If improving and increasingly comfortbale -> recommend to still revisit with RV in coming days/weeks for possible radiography of stifles, especially if having another flare up/episode of pain in LHL in future.    Vital Signs    Weight: 28;