C10032618 / invoice 10000

Reason:   Limping
History:  O reports limping this morning after she got up, very obvious especially at first, slowly over the day has settled.
Was a foreleg but O not sure which.
Usually manages short walk to park and then runs off lead.  No unusual activity lately
EDUF all normal and otherwise well.

Examine: 
Mentation: BAR, nervous but likes treats
Body condition score: 3/5
MM:    pink and moist            CRT: <2s
HR:      100          RR: pant
LN: nad
Temperature: ne

Ocular: nad
Oral/Dental stage: teeth a little worn but otherwise nad
Ears: nad
Cardiovascular: nad
Respiratory: nad
Gastrointestinal: nad 
Integumentary & lumps (measurement, location):nad
Musculoskeletal:  no lameness in consult, no leg/back/neck pain in consult, well behaved for exam
Urogenital: nad
Neurological: nad

Problem List:
Assessment: 
Foreleg lameness: unable to localise today

Treatment: 

Plan: 
Rest a couple of days then go back to normal activity if no further lameness.
If ongoing issues then recheck (and O to make note of which leg it was).
Briefly mentioned nsaids if ongoing lameness (+bloods), mentioned 4 cyte.  Is currently on some sort of joint supplement and fish oil.

Followup: 

Presented with/REASON for visit:
vacc
Salient HISTORY: all well
No vomiting, no diarrhea, or tenesmus
Normal appetite. 
No polydipsia or polyuria
No coughing.

Current MEDICATIONS: -
Allergies: none we are aware of

Preventatives and Vaccinations: KC due
Body Condition Score: 5/9.

Patient compliance with this exam- (compliant/limited/ restricted) = compliant

VITALS: Heart Rate - approximately 120, Mucous Membranes pink, moist, Capillary Refill Time ~2 seconds, Respiratory Rate ~26, Temperature 38.7°C.

MENTATION: Bright, Alert, Responsive.

HEAD:
Eyes: No conjunctival or scleral vessel injection/congestion, no blepharospasm, or discharges. Cornea clear /moist, limited vision of anterior posterior chambers.
Ears: No discharge or discomfort.
Nose: No significant findings, no discharges noted during examination.
Oral: No significant findings, dentition ~1/4.

INTEGUMENT: No significant findings, coat condition is fair, skin turgor normal. Pruritis 1/10

CARDIOVASULAR System: No murmur detected. Pulses synchronous and normodynamic.
RESPIRATORY: Normal breathing effort and normal bronchovesicular sounds both hemithoraces.

ABDOMEN: Mild abdominal splinting at the time of examination, no significant reaction on palpation of abdomen. No organomegaly detected.
Rectal: Not performed, externally normal.
Urogenital: No discharge observed.

Lymph Nodes: Palpable peripheral lymph nodes within normal limits.

NEUORLOGICAL: Cranial Nerves - Facial sensation intact, pupils equal and reactive to light, head carriage normal, no spontaneous nystagmus or deviation of eyeballs.
Spinal Nerves - no ataxia, voluntary motor functions intact in all limbs. Full neuro exam not done
MSK: Normal ambulation observed during consultation. Adequate muscling in all appendicular limbs. No CREPI in main joins examined. A full musculoskeletal examination not performed.

Summary of Problems:
Unremarkable PE, healthy for age
Recommended/Additional DIAGNOSTICS:
-AH blood panel -) declined for today had one recently see HX GHP mild AST and CK increase all else well now
TREATMENT and PLAN- discussed with Owner:
vacc Pi2 and i/o BB (5264015/5245-41B)
discussed preventatives wormer, potential vaccination s/e
Revisit as indicated.

TAHP results

very mildly elevated AST
elevated CK, poss from multiple attempts in collecting bloods

Cannot r/o hyperA with the PD + mildly elevated AST but O declined testing as P is VERY difficult to get bloods and require inj sedation to get bloods which O cant afford to keep doing it for the LDDST
rec abd u/s to check for any kidney changes or adrenal gland changes but O declined as well and opted for monitoring for now

no longer limping. O said P has been drinking a lot since O had P