C10032138 / invoice 10000

Reason: Recheck - RHL LamenessAppointment Notes: See A/H by DF on Friday - acute onset RHL lameness. Pe quite unremarkable (see my notes). Started medical management. RV appt booke din case not alot better. Bec would consider rads if lameness not substantially improved. DFHistory: Was seen after hours last night for acute onset RHL lameness. Couldn't find the area of pain last night but treated with gabapentin and meloxicam. Settled last night but still notwanting to use the leg. Doesn't want to walk, owner has had to carry him around. Not interested in food this morning. Didn't eat anything.Dental score: Body Condition Score: 9/9 - obesePain Assesment Score: Grade 4/4 lame in RHLPhysical Examination: Obese.Very stoic. Will stand and toe-touch when has to but prefers not to put any weight on right hind leg. Will sit down as soon as can and refuse to walk. Neck and spinal palpation feels fine. Hip appears to be ok on manipulationStifle has some pain, particularly around proximal tibia. Hock and foot feel fine. Didn't get a good feel of cruciate as too tense. Differential Diagnosis: Fracture vs ligament damage. Discussed with Rebecca that sedation and radiographs are a good idea as cannot get a Dx on physical exam without them. Owner agrees. Admitted for sedation and radiographs of RHL and lumbar spine. Laboratory: Pre-GA bloods: Hyperalbuminaemia (dehydration?) and slight lymphopeania (stress-response?), otherwise fine. Treatment:Sedated with Radiology: No fractures. Does have some osteolysis in distal femur on right leg. Treatment: Meloxicam sid with food 7 days. Rest/confinement, Plan:    Vital Signs    Weight: 22.1;       MMColour: pink;       HeartRate: 120;       BodyScore: 9/9;       DentalGrade: 1/4;       RespirationRate: 20;       CRT: 1 sec ;