C10030863 / invoice 10000

Appointment Notes: hurt her legHistory: Seen 3d ago for RHL lameness > this has since resolved Today has now injured her LFL - she was jumping up on the baby gates, and then was limping after she got down. Yelped once since then, otherwise just mildly lame. D+ has now resolved, current meds = gabapentin BID (started due to HL lameness). Subjective:  bar, sweetest girl, likes giving hugs. Objective: HR/PR/CV: 96, auscultation nad, no murmur or arrhythmia PULSE: normokineticTemp: n/eMM/CRT/Hydration:  pm, 1sec, normal skin turgor, adequate hydrationRR/RESP:  24, lung fields clearGIT: abdominal palpation comfortable and unremarkableSkin/Ears: healthy skin and coat, ears clean externally M/S: > G1-2 lameness LFL. No obvious HL lameness, though slightly short striding. > HL: nad on full ROM. Spine nad on palpation. > LFL: distal limb nad (paw pads, nails, digits, metacarpals all nad); carpus non repeatable crepitus on flexion but no pain noted and full ROM achieved; elbow nad; shoulder stiff for final 20% of extension, otherwise ok on ROM. Shoulder+neck musculature twitching during shoulder extension. > Stiff on L lateral neck flexion (80-90% ROM achieved), otherwise full neck ROM achieved, nad on palpation. Eyes: clearLymph Nodes: nad BCS: 5/9Assessment: 1. RHL lameness resolving, ongoing mild stiff ambulation > ddx: ST injury, stifle diz, tarsal OCD/DJD, corn (not seen), other2. Acute LFL lameness > ddx: shoulder pain (ST injury, OCD, DJD flare), referred neck pain (ST injury, IVDD, other), other. Treatment: Add in metacam now that D+ has resolved > 2.5mg PO SID 3-7d until lameness has resolvedContinue gabapentin as previously prescribed Plan: Keep rested until lameness resolvesINI consider FL CT next step (+/- HL x-rays if any recurrent HL lameness)FUC 3d    Vital Signs    Weight: 25.4;