C09982805 / invoice 10000

NURSE: EL

REASON: Reason for presentation: Medication review and refill. Worsening weakness in the hindquarters.

HISTORY:
Reports episodes of hindlimb weakness and ataxia, occurring 3-4 times. During episodes, hind feet knuckle over and unable to move legs, requiring support to stand. Episodes are short, with a return to normal function. Reports some general stiffness on rising between episodes. Condition has worsened over time.
Mild heart disease and kidney disease. History of anaesthetic complications, including prolonged recovery. Previous dental cleaning under general anaesthesia.
Diet consists of a combination of a veterinary diet and homemade food with vegetables.
Lives in a house with stairs; a large ramp with marine carpet has been installed. Receives daily short, flat walks, once or twice daily.

APPETITE: Not assessed
ACTIVITY: Worsening weakness in the hindquarters. Stops for breath on walks. Fell down stairs recently. General stiffness on rising.
DIET: Combination of veterinary diet and homemade food including vegetables.
TOILETING: Not assessed
CURRENT MEDICATIONS: Not currently on any pain relief.

**CLINICIAL EXAM:**
Mentation: BAR
MM: Not assessed
-CRT: Not assessed
Oral and Dental Score: Significant dental calculus present, particularly on the upper teeth. Bottom teeth are in good condition.
Eyes: Not assessed
Ears: Not assessed
BCS: Has gained a little weight.
Lumps: Not assessed
Abdominal: Not assessed
Lymph nodes: Not assessed
HR: Not assessed
RR: Increased panting, can be spontaneous. Panting and stopping for breath on walks.
Temp: Not assessed
Urogenital: Not assessed
MSK: Marked tenderness on palpation over the lumbosacral area, causing weakness and sinking. Episodes of hindlimb weakness/ataxia with proprioceptive deficits (knuckling).
Skin: Nails have long quicks.

**ASSESSMENT:**
Clinical signs are highly suggestive of lumbosacral disease with nerve root impingement.
Problem list:
    1. Suspected Lumbosacral Disease
    2. Severe Dental Disease
    3. Mild heart disease
    4. Kidney disease
    5. History of anaesthetic complications

DISCUSSION:
Communicated to the owner that clinical signs suggest lumbosacral disease, likely due to arthritis pinching the nerves controlling the hind legs.
Discussed gold standard treatment involving a CT scan for diagnosis followed by epidural cortisone injections, noting the anaesthetic risk and cost. An estimate was provided for insurance purposes.
Discussed severe dental disease, noting the anaesthetic risk for a scale and polish.
Provided education on at-home dental care, including daily brushing and the specific, supervised use of large, raw, non-marrow bones for mechanical cleaning. Acknowledged the risk of tooth fracture.
Discussed nail trimming technique for long quicks, recommending frequent, small trims with an electric grinder.

TREATMENT:
Multimodal pain relief commenced.
Panadol Osteo: Half a tablet twice daily (morning and night).
Pregabalin: To be dispensed. Owner advised of potential for increased hindlimb weakness.

PLAN:
Recommended a CT scan of the lumbosacral spine for definitive diagnosis.
Recommended a course of three epidural cortisone injections, two weeks apart, as the most effective treatment option post-diagnosis.
Monitor response to pain relief at home.
Re-evaluate if clinical signs worsen or fail to improve.
At-home dental care including daily tooth brushing.
Continue frequent, small nail trims with an electric grinder.