Thunder
Sunday, August 3, 2025 at 1:09 PM
Subjective
Chief Complaint
Thunder, a horse, presented for evaluation of lameness in the front left leg after a recent ride.
History
- Owner reported Thunder favoring his front left leg, particularly at a trot.
- Owner noted Thunder is typically stoic, so any signs of discomfort are unusual.
Objective
Vital Signs
- Temperature: WNL
- Weight: WNL
- Heart Rate: WNL
- Respiratory Rate: WNL
- Capillary Refill Time: WNL
- Body Condition Score: BCS 4-5/9
Physical Exam
- Eyes: Clear with no discharge
- Ears: Clean with no discharge or erythema AU.
- Oral: Teeth clean, no gingivitis or tartar.
- Cardiovascular: Normal heart rate, sinus rhythm, no murmurs. Strong and synchronous pulses bilaterally.
- Respiratory: Clear lung fields bilaterally, no crackles or wheezes.
- Abdominal: No organomegaly or mass effects. No pain on palpation.
- Lymphatic: No peripheral lymphadenopathy.
- Coat and Skin: Healthy hair coat and skin, no ectoparasites seen.
- Musculoskeletal: Slight swelling noted around the left front fetlock joint. Tenderness observed upon palpation of the tendon sheath. No severe injury detected.
- Neurological: Normal neurologic exam with normal mentation. No proprioceptive deficits or overt ataxia; normal cranial nerve exam.
- Neck and Thyroid: No peripheral lymphadenopathy.
- Reproductive and Urinary: Normal external genitalia, no discharge or inflammation.
- Mammary: No significant findings
- Rectal: Not examined
Assessment
Mild soft tissue injury, likely tendonitis, localized to the left front fetlock area.
Plan
- One week of stall rest with daily hand-walking for a few minutes.
- Cold hosing the fetlock twice daily to reduce inflammation.
- Prescribed anti-inflammatory medication with dosage instructions provided.
- Monitor for increased swelling, warmth, or lameness at the walk; reassess in one week.
- If no improvement, consider imaging (e.g., ultrasound) to evaluate for underlying tendon or ligament injury.
- Preventative measures discussed, including gradual warm-ups, frequent hoof checks, and potential use of protective boots or wraps for trail riding or work on hard surfaces.
Client Discharge Note
Thank you for bringing Thunder in today, Mrs. Thompson. It was a pleasure to see you both.
Summary
Thunder was evaluated for lameness in his front left leg, which was more noticeable at the trot. Upon examination, mild swelling was observed around the fetlock joint, and tenderness was noted during palpation of the tendon sheath. No sensitivity was detected with hoof testers, and his gait showed a slight head bob at the trot. Based on these findings, the likely diagnosis is a mild soft tissue injury, possibly tendonitis.
Key Topics We Discussed
- Stall Rest: Thunder should remain on stall rest for one week. Hand-walk him for a few minutes each day, but avoid lunging, trotting, or riding.
- Cold Therapy: Cold hose Thunder's fetlock twice daily to reduce inflammation.
- Medication: Administer the prescribed anti-inflammatory medication as directed. Dosage instructions have been provided.
- Monitoring: Watch for increased swelling, warmth, or lameness at the walk. Contact us immediately if any of these signs occur.
- Follow-Up: We will reassess Thunder in one week to determine if further imaging, such as an ultrasound, is necessary.
- Preventative Measures: Once Thunder has recovered, incorporate gradual warm-ups before exercise, check his hooves regularly, and consider protective boots or wraps for trail riding or work on hard surfaces.
Thank you for entrusting us with Thunder's care! Please do not hesitate to contact us if you have any questions or concerns.
— Dr Kim Lee