C09986533 / invoice 10000

Reason: Flat Lethargic Off For Past WeekAppointment Notes: erHISTORY:  Presented for assessment of lethargy, quietness, reluctance to stand, and significant fur loss over the past 2/52. The owner reports a significant change in behaviour; normally anxious and constantly by the owner's side, the dog is now very quiet, sleepy, and lying down a lot. It no longer greets the owner at the door and will remain in a room alone, which is abnormal.The primary concern is difficulty rising, seemingly affecting the hindlimbs. The front limbs appear normal. A subtle limp has been noted, but it is not a non-weight-bearing lameness. The difficulty is most prominent with the initial effort of getting up from a recumbent position; once standing, mobility improves. The owner suspects a possible injury from the backyard, but there was no specific incident witnessed. Today, the dog seems slightly brighter and more mobile, barking at the door upon the owner's arrival.Appetite is reduced, with eating slower than normal, though appetite is still present. Bowel movements and urination are normal. No V+ or D+. There is significant, diffuse fur loss, described as coming out in handfuls.There is a past history of IMHA and IMTP requiring hospitalisation for 5/7 for investigation and treatment. Clotting times were reportedly normal at that time. The owner mentioned a query about possible rat bait ingestion from an ex-partner's property around the time of the previous illness, but this was unconfirmed. Current meds: noneVaccination: Not mentionedParasite Prevention: Not mentionedPre-existing conditions: Immune-mediated haemolytic anaemia (IMHA) and immune-mediated thrombocytopenia (IMTP).Access to toxins eg. Rodenticide: none EXAMINATION:MM: pink and normal refill (no petechiae)Cardiovascular: 110 bpm, cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal discharge. Panting noted during consult.Neurological: neurologically no significant findingsMusculoskeletal: ambulating normally, palpable pain in the lumbosacral region on palpation. As soon as I touch her there she goes down Gastrointestinal:- Oral: normal, no mouth pain, dental score (1-4): not graded- Abdominal: no detectable pain on abdominal palpation- Rectal: not performedUrinary: NSFReproductive: NSFIntegument/Ears: NSFLymph Nodes: NSFEyes: NSFDemeanour/Behaviour: Quiet but alert during consultation. PROBLEM LIST:- Suspected lumbosacral pain/soft tissue injury- Lethargy and behavioural changes- Reduced appetite- Diffuse fur loss- Hx of IMHA/IMTP DIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:Suspected soft tissue injury (lumbosacral). DIAGNOSTICS:Bloods were taken for in-house testing:- Please find attached to the patient record.> Complete Blood Count- large platelets  > Biochemistry- Significant findings: No remarkable findings. Interpretation: Haematology and biochemistry are within normal limits. No evidence of active infection or recurrence of IMHA/IMTP. ASSESSMENT:  The clinical presentation with reluctance to rise, improvement once mobile, and pain localised to the lower back on examination is highly suggestive of a soft tissue injury, likely related to the lumbosacral spine. The behavioural changes, lethargy, and reduced appetite are likely secondary to pain. In-house blood tests have ruled out systemic disease, infection, or a recurrence of the previous immune-mediated conditions. The fur loss is noted but will be addressed secondarily, as pain is the primary issue. A therapeutic trial with NSAIDs is warranted. TREATMENT:  - Meloxicam dispensed: 1.5 tablets PO SID with food. PLAN:- Commence a trial of anti-inflammatory medication for one week.- Strict rest is advised. Avoid running, jumping, or strenuous activity. Leash-walk only for toileting purposes.- Re-evaluation in one week's time to assess response to treatment.- If there is no improvement, further diagnostics, including imaging (radiographs), will be recommended to investigate for bony pathology.- Home into owner's care. CLIENT COMMUNICATION:Discussed that the most likely cause of the signs is soft tissue pain in the lower back. The plan is to start a one-week trial of anti-inflammatory medication (Meloxicam) and enforce strict rest. Advised to administer the medication with food and to discontinue use and contact the clinic if any vomiting, diarrhoea, inappetence, or dark stools are observed. The owner was counselled that if there is no improvement, the next step would be radiographs to assess for bony changes, but that soft tissue injuries are not visible on x-ray. The owner understands the plan.    Vital Signs    Weight: 19.4;