C10025972 / invoice 10000

Lame -
Vetstoria Appointment
Consult - General
PRESENTING COMPLAINT:  
(Lame)

SUBJECTIVE/ HISTORY:
O'  reports improvement after visit last year.
O'  has noticed intermitent lameness RF, but is becoming more frequent.
Previously after rest, but now regular lamaness.
EDUF ok, well within self.
No meds.
No other health concerns.
  Appetite: (normal)
  Water Intake: (normal)
  Urination: (normal)
  Faeces: (normal)
  Current Medications: (nil)
  Vaccination Status:  (UTD)

OBJECTIVE/ EXAMINATION:
Temperature:(not taken)
Mentation (BAR) BCS:(6)/9
Hydration:(ok)
Mm pink and moist, CRT <2 sec
Dental:(nad)
Oral exam: (nad)
Eyes: (nad)
Ears: (nad)
HR: (108) bpm, rhythm (normal), Mumur (nil), pulses (synchronous)
RR: (panting) pm, effort (nil), Aus pulmonary fields (normal)
Abdominal palpation: (comfortable)
Integ: subcutaneous mass upper caudal R thorax, approx 1.2cm, present 1-2 months unchanged.
Msk: (RF - reduced ROM in carpus and elbow.
LF - reduced ROM in carpus (better than RF though), and mildly reduced ROM in elbow.
Mildly reduced ROM in both hips)
Peripheral LNs: (nad)
Neurological: a full neurological exam not performed

LABORATORY:
(Nil)

ASSESSMENT/ PROBLEM LIST:
(Sore RF)

DD's:
(Sore RF - acute on chronic OA, hyperflexion injury/soft tissue injury)

TREATMENT:
(1. carprofen 50mg bid 2 weeks, with food
2. rest initially
3. then lught leash walking only.)

PLAN:
(Recheck 10-14d to assess response to pain relief trial +/- x-rays (estimate given).)

OWNER COMMUNICATION NOTES:
(Discussed with O:
1. sore limbs - suspected OA, but cannot rule out other causes. Discussed x-rays with O'.
Also discussed medication trial - O'  keen to trial this, dec senior bloods today, may consider if using long term.
Start carprofen and recheck 2 weeks.
INI or deterioration, then x-rays.
Discussed jt care:
- vhome care - bedding, exercise, weight loss and jt supps
- vet care - zydax inj, anti-inflam, pain relief, Beransa.
2. lump - inflam vs infect vs neoplasia - suspected neoplastic mass. Discussed FNA, O'  going to monitor initially.)