C09983934 / invoice 10000

REASON: RIGHT pelvic limb lamenessREFERRING VETERINARIAN: Francesca @ VetWest YokineHISTORY: Approximately 4–5 weeks ago, the dog acutely developed non-weightbearing lameness of the RIGHT pelvic limb while playing. Initially there was concern for a limb injury; however, following veterinary assessment this was considered more consistent with intervertebral disc disease. He has been managed conservatively with strict cage rest, gabapentin, and trazodone (for confinement and separation anxiety). The first few weeks were painful, but over the past two weeks there has been marked improvement. Occasional slipping on wooden floors and mild transient lameness if he rushes or becomes excited, but overall significantly improved. No urinary or faecal incontinence reported. No previous episodes of back pain. Known to be generally anxious with separation anxiety.Medications: Gabapentin; trazodone.Imaging: None performed.EXAMINATION:Gait: Symmetrical and appropriate weight bearing on all four limbs at walk.LEFT Thoracic Limb: NSF - breed-associated antebrachial deformityRIGHT Thoracic Limb: NSF - breed-associated antebrachial deformityLEFT Pelvic Limb: Unremarkable on neurological and orthopaedic examinationRIGHT Pelvic Limb: Unremarkable on neurological and orthopaedic examination Mild discomfort elicited on firm spinal palpationASSESSMENT: Suspected thoracolumbar intervertebral disc extrusion, improving with conservative management. No current neurological deficits.PLAN: Gradual return to controlled exercise following completion of strict rest period. Taper and discontinue gabapentin over the coming days if comfortable. No advanced imaging or surgical intervention recommended at this stage. Reassessment advised if any deterioration, recurrence of significant pain, weakness, or incontinence.CLIENT COMMUNICATION: Discussed that clinical signs and history are consistent with an intervertebral disc extrusion that has responded appropriately to strict rest and medical management. As he is ambulatory, symmetrical, and neurologically normal on examination, advanced imaging (CT) is not recommended at this stage, as it would not alter management. Surgery is not indicated given his improvement. Advised gradual increase in controlled lead exercise and monitoring for any signs of deterioration. Explained that recurrence is possible with disc disease, and that prompt reassessment would be required if pain, weakness, or continence changes develop. Discussed practical lifestyle modifications to reduce spinal strain where feasible (e.g. limiting high-impact jumping), acknowledging this may be challenging. Owners advised to contact the clinic with any concerns.    Vital Signs