C09983018 / invoice 10000

Reason: Lameness RHLHISTORY:Presented for acute onset non-weight bearing lameness of the right hindlimb after being accidentally stepped on this evening. The owner reports Monty yelped and pulled away, and has been non-weight bearing since. A significant change in demeanour has been noted, becoming very passive and subdued, which is abnormal. Eating and drinking have been normal prior to this event.Known history of anal gland adenocarcinoma diagnosed approximately one year ago with widespread metastases. Prognosis at diagnosis was 6 months. Initial lethargy and irritability improved significantly with treatment, becoming bright and active.Historical aversion to having hindquarters touched and being picked up. Previously noted some hindlimb weakness and slipping on floors post-diagnosis.Current meds: Piroxicam one tablet daily. Gabapentin 100mg one capsule in the morning (prescribed 200mg twice daily).Prophylaxis: [State prophylaxis status including vaccinations and deworming treatments]Pre-existing conditions: Anal gland adenocarcinoma with metastases.Triage:HR: 120RR: 20Temp: 38.2Mm: pink and moistCrt: <2Mentation: Quiet and subduedEXAMINATION:Body Condition Score: 5/9Pain Scale (0-4): 2/4Hydration status (%): EuhydratedCardiovascular: cardiac ausculation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: Mentation appropriate. Plr positive , menace positive, palpebral positive . No abnormal strabismus or nystagmus positional or otherwise noted. Normal facial sensation and motor. Normal facial symmetry. Normal gag reflex. No neck pain. CPs and withdrawals present in all limbs. Patella reflexes intact. Cutaneous trunci reflex WNL. Strongly ambulating with no observable ataxia. Normal posture. Perineal reflex WNL. Adequate anal tone. Full exam not performedMusculoskeletal: Non-weight bearing lameness of the right hindlimb. No crepitus palpable. Marked pain response on external rotation of the right hock, and abduction and extension of the right coxofemoral joint. The area where the paw was stepped on does not appear painful on palpation. No cranial drawer or tibial thrust evident in the stifle.Gastrointestinal:Oral: mild dental diseaseAbdominal: Abdomen soft, non painful on palpation. No organomegaly or fluid wave appreciatedRectal: not performedUrinary: no significant findingsReproductive (incl ext genitalia): no significant findingsIntegument/Ears: clean and shiny haircoat. No skin masses of lesions noted. No fleas or flea dirtLymph Nodes: peripheral lymph nodes palpable < 1cmEyes: no significant findingsPROBLEM LIST:1. Acute, non-weight bearing lameness right hindlimb.2. Pain on manipulation of right hip and hock.3. Metastatic anal gland adenocarcinoma.DIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:Soft tissue injury (sprain/strain) of the right hindlimb.Orthopaedic injury (e.g., fracture, luxation) - considered less likely.Exacerbation of pre-existing orthopaedic condition (e.g., arthritis).DIAGNOSTICS:Radiographs were discussed but declined by the owner at this stage in favour of trial medical management.ASSESSMENT:Acute right hindlimb lameness likely secondary to a soft tissue injury from a hyperextension or twisting event when pulling away after being stepped on. Orthopaedic injury is a differential but considered less likely based on examination findings. The pain appears to originate from the hip/hock region rather than the foot itself.O declined radiographs tonight i n favour of trialling analgesia.TREATMENT:Methadone 0.3 mg/kg administered subcutaneously for analgesia.Advised to continue piroxicam at current dose.Advised to increase gabapentin dose to the prescribed 200mg twice daily to improve analgesia.PLAN:Monitor at home.Re-assessment advised if there is no improvement in lameness over the next 24 hours.If lameness persists or worsens, radiographs of the right hindlimb under sedation are recommended.CLIENT COMMUNICATION:Discussed the likely cause of lameness being a soft tissue injury. Explained the two main options of strong pain relief versus radiographs tonight. The owners have elected for pain relief and monitoring. Advised that if it is a soft tissue injury, improvement should be seen by tomorrow, whereas an orthopaedic injury is unlikely to improve. Instructed on increasing gabapentin dose. Advised to return for re-evaluation and potential imaging if Monty is not improving.    Vital Signs