C09972172 / invoice 10000

HISTORY - Dr Mikayla Clowes
Maple is a three year old female spayed Dachshund presenting for intermittent yelping over the last three days, predominantly noted in the mornings. No lameness has been observed. On the first day of presentation, she was noted to yelp when turning on the bed. She did not eat her biscuits immediately that morning, instead wandering around before eventually eating them, though they were not as appealing to her as usual.

This occurred only on the first day and she has been eating normally since. She remains responsive when the yelping occurs and does not appear disorientated. No seizure-like activity has been observed.

No wobbliness, drunken gait, scuffing, stumbling, or crossing of limbs has been observed.

She otherwise appears normal aside from the intermittent yelping episodes.

Current Medications: None

Routine History:
Other known disease: None
Behaviour or activity: Normal, no changes in behaviour noted
Eating: Normal, eating normally
Diet Changes?: No changes
Drinking: Normal, drinking normally
Urinating: Normal, urinating normally
Defecation: Normal, no diarrhoea
Seizures/Collapse: No
Coughing: No
Sneezing: No

Physical Examination

BCS: 6 out of 9.
LOC: Normal. BAR.
TEMPERATURE: 39.5C
AMBULATORY STATUS: Ambulatory and normal.
CARDIOVASCULAR: Normal. HR 120bpm. Normal sinus rhythm. The mucous membranes were pink, and moist. The CRT was < 2secs. Auscultation revealed no murmur. The femoral pulses were strong.
RESPIRATORY: Normal. RR 30brpm. The respiratory effort was normal. Auscultation revealed no abnormal sounds or noises.
GASTROINTESTINAL: Normal. The oral cavity appeared normal. Abdominal palpation normal. A rectal examination was not performed.
UROGENITAL: Normal. The urinary bladder palpably normal. The external genitalia was normal.
OPTIC: Normal. Unremarkable.
AURAL: Normal. Unremarkable.
INTEGUMENT: Normal. There were no abnormalities.
LYMPHATICS: Normal. The peripheral lymph nodes were within normal limits.
NEUROLOGICAL: Normal. Normal mentation and attitude. No appreciable deficits, full neurological examination was not performed.
MUSCULOSKELETAL: Abnormal. Ambulatory, but with TL spinal pain.
OTHER COMMENTS: No.

DIAGNOSTIC SUMMARY

none indicated
PROBLEM LIST

Intermittent yelping, predominantly in the mornings, over the last three days
Differentials include:

Disc disease vs MSK/soft tissue injury
ASSESSMENT
Maple presents for squealing from possible back pain. Only noted pain response was thoracolumbar spinal pain. This could be a disc issue or soft tissue injury.
There is no indication for imaging at this stage. Conservative management with pain relief is appropriate.

TREATMENT ADMINISTERED

Meloxicam 0.1mg/kg PO SID
Gabapentin 10mg/kg bid po

PLAN
Options discussed with owner include:

Conservative treatment with pain relief
No indication for imaging at this stage
Plan is:

Meloxicam at 0.1 mg/kg once daily for at least five days
Counselling provided regarding managing back conditions in Dachshunds
Weight loss recommended, she likely needs at least one kilogram lost
If no improvement, seek an appointment with regular veterinarian this week or return to us, particularly if neurological deficits are present