C09973939 / invoice 10000

sore leg/back. dc

Verified: NO

HISTORY
Presenting for: Millie, a 12-year-old Dachshund, presented for acute onset of walking abnormally following an incident yesterday where she appeared to jump or fall awkwardly.

Historical Conditions:
- Recent dental procedure (end of last year) with blood work showing normal kidney and liver values
- Occasional frothy vomiting episodes every few weeks (chronic intermittent issue)
- Hair regrowth on back noted over past month since discontinuing previous medication
- Granddaughter's low bed jumping incident mentioned as potential trigger

Diet:
- Eating normally with no changes noted

Drinking/Urination:
- Normal water consumption, occasionally drinks from 2-3 bowls but not considered excessive

V/D/C/S:
- Occasional frothy vomiting noted 2-3 weeks ago, described as chronic intermittent issue
- No recent vomiting or diarrhoea

Current Meds:
- Recently discontinued medication (timing correlates with hair regrowth)
- Previously on Meloxicam post-dental procedure for 2-3 days

Lifestyle Risk Factors:
- Access to low furniture (granddaughter's bed) that patient can jump from

Other:
- Owner restricting jumping and keeping patient on blanket to prevent further injury
- Patient normally very active, jumping up on owner, but currently reluctant to do so
- Symptoms improved slightly from yesterday but patient still not herself
- Owner travelling to Tasmania Thursday, patient staying with daughter for one week

EXAM
Wt: 5.9 kg
Behavioural: Cooperative during examination, panting noted
Abdominal: Tense abdomen with guarding behaviour, patient resists when lower spine palpated and pushes against examiner
Neurologic: Wobbly gait with occasional scuffing of hind feet and crossing of legs indicating proprioceptive deficits. Conscious proprioception testing shows sluggish response bilaterally, right side quicker than left. Patient maintains voluntary motor function.
Musculoskeletal: Lumbar spine pain evident - patient sits down immediately when lumbar region touched and shows resistance to spinal palpation. Pain localised to lower back/mid spine region. Reluctant to jump or perform normal activities.

ASSESSMENT
Suspected intervertebral disc disease (IVDD) - Likely disc protrusion causing pain and mild neurological dysfunction. Patient presents with characteristic signs including spinal pain, proprioceptive deficits, and gait abnormalities. Symptoms consistent with early stage disc disease with pain and mild neurological involvement but retained voluntary motor function.

PLAN
New Meds/Tx:
- Previcox 57mg tablets, 1/2 tablet daily for 2 weeks. Prescription sent to Pet Chemist for collection. Discontinue immediately if black tarry stools or diarrhoea develop.
- Gabapentin provided as interim pain relief with muscle relaxant properties until Previcox available

Additional Discussion:
- Strict crate rest recommended for 4 weeks to allow disc inflammation to settle
- No jumping, climbing, or back arching activities permitted
- Proper lifting technique demonstrated - support under chest and hindquarters
- Specialist referral and spinal imaging available if condition worsens or fails to improve with conservative management
- Monitor for progression of neurological signs which would warrant immediate specialist consultation

Client Comms:
- Discussed conservative management approach appropriate given patient's age and current mild symptoms
- Explained IVDD progression stages and importance of strict rest
- Advised to monitor for worsening neurological signs or development of gastrointestinal upset from anti-inflammatory medication
- Treatment plan suitable for upcoming travel arrangements with daughter providing care