C09973692 / invoice 10000

Reason: Mass on R hip Diagnosed acute polyradiculoneuritis at QVS in November, tetraparesis presentation. Has been slowly improving, some strength in HL>FL but not able to walk still. Toileting ok.Seen by QVS with an infected swelling on her right hip - end of Jan. Started ABs and it went away. Has come back - swollen again. Not licking or bothered by it. Owner reports weekly gradual improvement in strengthNo current medicationsEXAMINATION:BAR, MM pink, moist, CRT < 2 secBody Condition Score: 3.5/9, muscle wastage from disusePain Scale (0-4): 0/4Hydration status (%): hydration clinically adequateCardiovascular: cardiac auscultation normal, no murmur/arrhythmia, pulse pressures normal and synchronousRespiratory: thoracic auscultation normal BV sounds bilaterally, respiratory effort and rate normalNeurological: paraplegia, some voluntary movement both for & hindlimbs, minimal strength front paws, improved voluntary movement back limbs compared to initial presentationMusculoskeletal: severe muscle atrophy, sternally recumbentGastrointestinal:- Oral: no oral lesions, dental score (1-4): grade 0- Abdominal: soft, comfortable, no abnormalities on palpation- Rectal: not performedUrinary/Repro: continent, no urine scalding noted, clean perineumIntegument/Ears: SC swelling right hip, 2 scabs overlying. Squeezed and expressed caseous purulent dischargeLymph Nodes: all <1cm, soft & symmetricalEyes: eye open/comfortable, L eye enucleatedASSESSMENT:- Chronic tetraparesis- Infected mass right hip regionPLAN:- Treatment: Antibiotics 5 days, chlorhexidine wipes for topical antiseptic cleaning of hip lesion- Follow-up: Monitor response to antibiotic therapy, return if lesion worsens or fails to resolve- Contingencies: Consider surgical excision if conservative management fails, anti-inflammatories if pain develops- Client Communication: Discussed ongoing nature of paresis, gradual improvement noted, importance of continued nursing care and physiotherapy for limbs, advised to continue current management approach    Vital Signs    Weight: 4.1;