C09989001 / invoice 10000

CLINICIAN: LC
PRESENTING COMPLAINT: 2 week spinal revisit
HISTORY:
- Pediculectomy T11-12 RHS performed on 12/2/26. Surgeon VWH. Grade 2 pre-op. 
- Peanut has been doing well since surgery. Owners have brought rugs at home to provide more traction when Peanut is walked to the toilet. She is ambulating well, urinating normally. Owners happy with progress. EDDU normal, no V+ or D+. 
- Owners have been going to physiotherapy. 

CLINICAL FINDINGS: 
BAR, vitals WNL
Neurological: Able to ambulate well with mild hindlimb ataxia in consultation. Delayed CPs on LHL, normal CPs on RHL. Normal withdrawal, patella reflex. 
Integument: Surgery site has healed well. 

DIAGNOSIS: Grade 2 spine

TREATMENT: None

CLIENT COMMUNICATION/PLAN:
- Very pleased with Peanut's progress. Continue resting Peanut for 2 more weeks and then can slowly integrate her onto normal exercise over 4 weeks. She may start hydrotherapy next week, this will greatly benefit her recovery. 
- No further revisits indicated unless she declines in her proprioception. If concerned, pleased seek veterinary attention. 

Post-Op Call
Call made by: HS
Number of days post-op: 11
Suture line condition: Physio reports wound looks really good, no swelling or redness
Fentanyl patch removed: Yes
Any issues with medications: Meds have kept her calm to an extent., but if o tries to leave house then she screams
Pain levels: Managing well
Activity level: Walking since day 3
Other notes: 26/2 booked for revisit. O would like to know if can up dose of traz or gaba as when she tries to leave the house Peanut screams and throws herself around the crate. Has been giving half traz tablet instead of full so suggested giving full dose and with gaba as o has been giving in the morning then in the afternoon.

CLINICIAN: ET

PRESENTING COMPLAINT: Day 1 post mini pediculectomy for Hansen type I IVDD

HISTORY: 
Surgery performed: mini pediculectomy at T11-12 RHS
Date performed: 12/2/2026     Surgeon: VWH
Grade 2 (ambulatory paraparesis) pre-op

CLINICAL FINDINGS: 
BAR
MM pink, CRT <2s
T: 37.5
CV: wnl
Resp: wnl
Neuro:
- Mentation: normal
- Gait: ambulatory paraparesis (grade 2) with mild ataxia
- Postural reaction: normal FLs, absent both HLs
- Reflex: normal withdrawal, patellar and perineal reflexes. Cutaenous trunci wnl LHS, stopped at caudal thoracic on the RHS

DIAGNOSIS: 
1 day post T11-12 mini pediculectomy - fit for discharge

PLAN: 
As in discharge notes