C10032912 / invoice 10000

Reason: Lame HLConsultation Time:19:40HISTORY:- Presented after running into a pole at high speed while chasing a ball.- Impact was to the left side.- Immediately following the incident, was unable to bear weight and was falling over.- Now able to ambulate but is reportedly "proppy".Eating and drinking as normal.No vomiting or diarrhoea.Previous relevant medical history:No underlying health concerns. No current medications. Owner notes a sensitive stomach.Subjective:QAR/BARObjective:Temp:39.0  MM: pink,moist CRT:<2   HR: 80 FP: 80  RR:pantingBCS: 5/9 Weight: 17.9 kgPain Score (0-4):0-1 /4CV: No heart murmur or arrhythmia noted. Femoral pulse strong & synchronous.RESP: Normal bronchovesicular sounds, normal resp rate/effort.GIT: Soft and comfortable on palpation. No obvious fluid wave no organomegaly.U/G: NAD. Rectal exam not performed.Neuro: No neurological deficits observed. CN intact. CP and withdrawal. Motor function is intact with no delays.M/S: Able to right, rise and ambulate on all fours. Mild soreness noted on palpation of the thoracic spine.Integ: Normal skin turgor.Ophth: NADLymph Nodes: NADPROBLEM LIST:Acute soft tissue trauma/pain secondary to blunt force traumaASSESSMENT: Jasper presented for assessment after running into a pole. On examination, neurological function is intact with no deficits identified. There is some mild soreness on palpation of the thoracic spine, but it is suspected to be muscular in origin. It is considered unlikely that there are any fractures, given the rapid improvement in ambulation. The initial inability to walk was likely due to shock and acute, severe pain. The plan is to manage with rest and analgesia. Owner was advised that swelling and soreness may worsen over the next 24 hours, but should then improve. Options offered to the owner included:1. Strict rest and a short course of oral anti-inflammatory medication.2. Re-evaluation if signs worsen or fail to improve.3. Advised to follow up with their regular veterinarian on Monday or Tuesday for a recheck if still concerned.TREATMENT:Meloxicam 0.1mg/kg PO SID for 3 daysPlan:Advised strict rest for the next 2-3 days, consisting of on-lead toilet walks only. No ball throwing or vigorous exercise. Supervised backyard access only to prevent any unexpected activity. If improving by Monday, can gradually reintroduce normal walks at his own pace. Recheck with us or regular vet if deteriorates, e.g., becomes more sore or shows increased lameness.    Vital Signs