AI-Generated Veterinary Referral Letter

Max

Thursday, July 31, 2025 at 2:30 PM

Referral Letter

Thank you for referring Max to our care. We appreciated the opportunity to evaluate him and are returning him to your continued management with our findings and recommendations below.

History

• Max, a 6-year-old neutered male Golden Retriever, was referred for evaluation of progressive left forelimb lameness noted over the past 3–4 weeks.
• The lameness is intermittent but worsening in frequency and severity, particularly after exercise or prolonged rest.
• The owners deny any known trauma. Max has no history of orthopedic disease but has a history of mild seasonal allergies.
• Appetite and energy levels are generally good, but the owner notes some reluctance to jump into the car or go upstairs recently.
• No vomiting, diarrhea, or other systemic symptoms reported.

Physical Exam

• Weight: 32.1 kg | BCS: 6/9
• Ambulatory with a noticeable grade II/IV lameness in the left forelimb.
• Pain and mild crepitus on flexion and extension of the left elbow joint.
• No instability detected. Mild muscle atrophy of the left shoulder and forelimb.
• Remainder of orthopedic and neurologic exam within normal limits.
• Cardiothoracic auscultation: Normal heart and lung sounds; no murmurs or arrhythmias.
• Temperature: 101.6°F

Diagnostic Investigations

• Orthopedic assessment: Positive elbow flexion test on the left side; range of motion mildly reduced.
• Radiographs: Lateral and craniocaudal views of both elbows. Findings include early periarticular osteophyte formation and sclerosis of the medial coronoid process on the left elbow. No fractures or evidence of ununited anconeal process.
• CBC/Chem/UA (recent, 2 weeks ago): WNL per referring DVM report.

Diagnosis

• Suspected medial compartment disease consistent with early medial coronoid disease (fragmented medial coronoid process unlikely at this stage) of the left elbow.
• Early degenerative joint disease (elbow dysplasia spectrum).

Treatments

• Prescribed carprofen 75 mg: ½ tablet twice daily with food for 10 days, then reassess.
• Started glucosamine/chondroitin supplement (Dasuquin Advanced) daily.
• Initiated omega-3 fatty acid supplement (Welactin) to support joint health.
• Recommended environmental modifications (e.g., carpet runners, ramp for car).
• Strict leash walks only; avoid high-impact activities.

Follow-Up

• Recommend recheck in 2 weeks for gait reassessment and response to medical management.
• If lameness persists or worsens, consider referral for CT imaging and arthroscopy of the left elbow to evaluate the extent of cartilage damage and plan surgical options.
• Long-term management will likely include ongoing joint support, controlled exercise, and periodic NSAID use.

Please don’t hesitate to reach out if you would like to discuss the case further or have any additional updates.

Sincerely,
Dr. Rachel Kim, DVM, DACVS
Veterinary Orthopedic Specialty Clinic