Rationale For Facts

C= critical, NC= non-critical, N= normal, A= abnormal

Small breed, Pomeranian- could be a breed/size disposition for her problem-NC, N
3 years old- probably not a congenital abnormality- NC, N
11.6 lbs- dog is somewhat overweight for her breed- NC, N
Lame in right hind leg- owner noticed a problem with the right hind leg- C, A
History of 1 year ago trauma-fell off bed- gives a possible explanation- C, A
Immediate weight bearing lameness RH, normal within a month-Current lameness may  
not be related, or we may be seeing degenerative changes because of this trauma- C, A
Return of mild RH lameness 6 mos later-could be related to trauma, current problem-C, 
A
Treated with anti-inflammatory drug injection, no real response-disease may not be 
inflammatory, or medical management may not have been adequate- C, A
Same mild lameness persistent but not worsening significantly for last 6 mos- describes 
history of lameness- C, A
No further treatment was performed- NC, N
Current on vaccinations and deworming, treatment for occasional allergies, Benadryl a 
week ago- routine care is good- NC, N

PE: grade 3/4 intermittent, non-weight bearing lameness of RH- describes lameness, 
coincides with owner's observations- C, A
Palpation of LH leg- elicited a pain response-couldn't do cranial drawer sign or patellar 
luxation, no other abnormalities- should repeat under anesthesia- NC, N
Pain response on dorsal flexion of tail- variety of explanations possible- NC, A
No pain on spine, lumbosacral palpation- NC, N
Dental tartar- possibility of infection/septic emboli originating from teeth-NC, N
Palpation of RH leg:
Medial buttressing possible on stifle- indicates that dog's body is trying to stabilize that 
joint- C, A
Cranial drawer is negative- does not rule out cruciate ligament rupture, should repeat 
under anesthesia- C, N
Patella easily luxated medially when leg was in extension- abnormal patellar motion was 
elicited- C, A
Upon flexion, patella returns to normal position- problem may be worse in extension than 
flexion- NC, A
No other abnormalities found in long bones, hip joints, muscles, or other joints of legs- 
helps rule out other problems- NC, N