C09984090 / invoice 10000

AM Came off pain relief
starting acting in pain again

Primary/Suspect diagnosis/location: (caudal vertebral fracture)
Suspect cause: (trauma)
Any other conditions being treated [if any]: (nil)
Known health concerns: (calcinosis cutis, allergic skin disease)
Date of first clinical signs [if known]: (a month ago) 

History:
Reason: ()
Diet: ()
Preventatives: ()
Medications: ()
EDDU: ()
Coughing/Sneezing: ()
Vomiting/Diarrhoea: ()
Current Diagnoses: ()
Hx:
()

Examination:
DEMEANOUR: ()
MENTATION: ()
GENERAL: BCS: ()/9; HR: (); RR: (); MM: p,m; CRT: <2; T: ()
EARS: no discharge, swelling or erythema
EYES: no discharge or erythema
NOSE: no discharge
ORAL: no discharge or halitosis; ()/4 dental disease
CV: no murmurs or arrythmias
RESP: clear bronchovesicular sounds on all fields with normal effort
ABDO: comfortable; no palpable abnormalities
UROGEN: no discharge or swelling
MSK: normal gait
NEURO: no gross defecits noted
DERM: no external parasites; good coat; no lesions, pruritus or erythema
LYMPH: no peripheral enlargement
RECTAL: not assessed

Problem list:
()

Diagnostics:
()

Assessment:
()

Client Communication:
()

Treatments:
()

Plan:
()

Discharge Instructions:
()

Verified: NO

History:
Reason: Tail chasing and lethargy
Diet: 
Preventatives: 
Medications: Metacam tablets (currently has some at home), anti-inflammatory tablets for pain management - one and half per day with food
EDDU: normal
Coughing/Sneezing: no
Vomiting/Diarrhoea: no
Current Diagnoses: Suspected tail fractures (2 past fractures and 1 new fracture identified)
Hx:
Patient was initially treated with tablets and liquid medication for one week, followed by Metacam tablets. Patient was well for 4-5 days then became lethargic again and resumed tail chasing/spinning behaviour. Had another 4 days of treatment, was taken off medication and symptoms returned. Currently has one tablet remaining and had one this morning. Patient is not sensitive when tail is touched and allows manipulation without reaction. Owner reports patient has been doing well overall but continues the spinning/chasing behaviour. Patient sits calmly during examination which is unusual for this normally active dog. Owner checked gums yesterday and they appeared normal. Patient recently had deck renovation with stairs moved, and yesterday attempted to jump up and down from deck rather than using stairs. Owner is having to guide patient to use stairs appropriately.

Examination:
DEMEANOUR: friendly
MENTATION: BAR
GENERAL: BCS: /9; HR: ; RR: ; MM: p,m; CRT: <2; T: 
EARS: no discharge, swelling or erythema
EYES: no discharge or erythema
NOSE: no discharge
ORAL: no discharge or halitosis; /4 dental disease
CV: no murmurs or arrythmias
RESP: clear bronchovesicular sounds on all fields with normal effort
ABDO: comfortable; no palpable abnormalities
UROGEN: no discharge or swelling
MSK: normal gait
NEURO: no gross abnormalities
DERM: no external parasites; good coat; no lesions, pruritus or erythema
LYMPH: no peripheral enlargement
RECTAL: not assessed

Problem list:
Suspected tail fractures with associated pain and behavioural changes

Diagnostics:
Previous X-rays showing 2 past fractures and 1 new fracture

Assessment:
Suspected tail fractures with ongoing pain management challenges

Client Communication:
Discussed ongoing tail fracture management options including continuing anti-inflammatory medication, potential specialist referral, and tail docking as last resort. Explained that fractures can take a long time to heal and immobilization is difficult. Discussed side effects of long-term anti-inflammatory use including potential kidney issues. Client expressed preference to avoid tail docking due to attachment to patient's tail. Discussed option of specialist referral for further evaluation and treatment options. Provided medication dispensing - offered box of 30 tablets vs 15 tablets due to minimal price difference. Discussed prescription requirements and repeat script options for long-term medication management. Offered to take back unused Metacam tablets for donation.

Treatments:
nil

Plan:
- Continue anti-inflammatory medication (Metacam) daily for one month
- Monitor response to treatment
- Consider specialist referral INI after one month of consistent treatment
- Tail docking to be considered as last resort option only

Discharge Instructions:
Give anti-inflammatory medication daily with food for one month. Monitor for improvement in symptoms. Guide patient to use stairs rather than jumping. Return for reassessment if symptoms worsen or no improvement after one month of treatment.