C09974160 / invoice 10000

?????SUMMARY* Follow-up for a 4-year-old Dachshund, Diego, recovering from a spinal injury. Owner reports gradual improvement in mobility and alertness, but ongoing challenges with urinary/faecal incontinence and difficulty posturing.* Diagnosis  paraparesis secondary to spinal injury, with neurological deficits more pronounced on the left side. Pain and anxiety appear well-managed with current medication.* Treatment involved weaning opioid analgesia by replacing two old fentanyl patches with a single 12mcg patch. More Gabapentin and Trazodone were dispensed. Plan is to recheck in 7-10 days and consider a hydrotherapy referral.History:History: Diego is presenting for a follow-up consultation after being discharged last Wednesday following treatment for a spinal injury. The owner reports he was initially sedated but has become progressively more alert and is now making more effort with his front end, sitting up, and starting to turn himself around. Challenges remain with mobility; he squealed when tangled in his harness and while attempting to defecate. Episodes of urinary incontinence occurred on Friday and today. He had soft faeces today. His appetite and water intake are normal. A pre-existing anxiety condition, which causes skin rashes, appears well-controlled on his current Trazodone medication.Exam:Demeanour: BARVital signs:- Heart Rate: not done- Respiratory Rate: not done- Temperature: not done- Eyes: eyes clear, no signs of conjunctivitis, pupils symmetrical and normal size- Ears: vertical ear canals clear, full otoscopic exam not performed today.- Oral: Mucous membranes pink, moist CRT <2s.- Nose: nares clear, no discharge- Peripheral Lymph nodes: no peripheral Lymph node enlargement palpated- Cardiovascular: No heart murmurs auscultated, normal rate and rhythm.- Respiratory: normal lung sounds with no crackles / wheezes- Skin: Skin condition is excellent with no evidence of rashes or excessive licking. The foot where a bandage was previously placed required cleaning.- Abdomen: relaxed on abdominal palpation, no masses or organomegaly noted. Bladder and colon palpated as normal.- Rectal examination: not done- Musculoskeletal: Ambulatory with assistance (harness/sling). Demonstrates paraparesis, with the right hindlimb appearing stronger than the left. Improved ability to sit sternally since discharge.- Other Findings: Defecated a small amount of soft faeces during the consultation.Problem List:* Paraparesis secondary to spinal injury * Urinary and faecal incontinence* Post-operative pain management* Situational anxietyAssessment:* stable since discharge following spinal injury.* increased alertness and front limb motor function.* Paraparesis persists, * Pain and anxiety appear to be well-controlled on the current medication protocol.Treatment:* Two old fentanyl patches and a bandage were removed.* The underlying foot was cleaned with Chlorhexidine solution.* One new Fentanyl 12mcg patch was applied.* Dispensed Trazodone.* Dispensed Gabapentin.* Advised to continue Paracetamol as previously directed.Client communications:* Discussed the plan to gradually wean Diego off potent opioid medication (fentanyl) to reduce side effects like sedation and reduced gut motility.* Advised that if progress continues, a referral for hydrotherapy could be beneficial for his rehabilitation.* Advised the owner to check her pet insurance policy regarding coverage for ancillary therapies like hydrotherapy.* Reassured owner that urination appears adequate despite incontinence episodes.Plan:* Recheck consultation in 7 to 10 days to assess progress.* Plan to weigh patient at next visit.Additional:-Notes for Reception:* Please schedule a recheck appointment for Diego in 7-10 days ish . with HR * Dispense one Fentanyl 12mcg patch, one box of Gabapentin, and Trazodone tablets.??O? could not pay for gaba today but will come back soon to pay and get them. In SDO carboard. BH ??    Vital Signs