C09994389 / invoice 10000

Reason: Suspected Spinal painHistory Summary:Cannon presented this evening for an inability to bear weight on his left hind leg, which was associated with spasms causing him to kick the leg out. He has a known history of intervertebral disc disease (IVDD) with three bulging discs and is currently managed with pain relief. Tonight, he had received his regular doses of pregabalin, meloxicam, and paracetamol with no improvement in his comfort or ambulation. He is also on trilostane for Cushing's disease and has a follow-up appointment scheduled with VSS on Friday.TRIAGE:HR: 128RR: PantTemp: 38.0°CMM: PinkCRT: 1-2 secondsMentation: BARPain Scale 0-4: 1-2Hydration status (%): Clinically adequateEXAMINATION:Body Condition Score: 5/9Cardiovascular: Cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: Thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: No significant findings, no cranial nerve or proprioceptive deficits/gait, full neurological exam not performed.Musculoskeletal: Unwilling to ambulate on the left hind leg. Examination of the left hind leg was difficult as he became snappy when attempts were made. Thoracolumbar pain on palpation.Gastrointestinal:- Oral: NSF- Abdominal: NSF- Rectal: not performedUrinary: NSFReproductive (incl ext genitalia): NSFIntegumentary system: NSFLymph Nodes: WNL on palpationEyes: NSFPROBLEM LIST:1. Acute left hindlimb lameness2. Spinal pain (suspected IVDD flare-up)DIFFERENTIAL DIAGNOSIS:The initial differential diagnoses included a flare-up of his known IVDD versus a separate acute injury to the left hind leg.DIAGNOSTICS/MANAGEMENT PLANInitial plan was for a full consultation following initial triage and examination to further investigate the presenting signs. Pain relief was administered.Nil performedTREATMENT SUMMARY:Methadone 0.3 mg/kg was administered for analgesia.REVISED ASSESSMENT:Acute lameness secondary to a foreign body (bindi) in the interdigital space of the left hind paw.  Bindi was found by owner after initial triage and pain relief.  Was removed during consult. Chronic spinal pain likely secondary to IVDD remains an ongoing issue.OWNER COMMUNICATION:Initially, a discussion was had with the owner regarding the possibility of an IVDD flare-up. After initial pain relief, the owner was able to feel his foot and suspected something was between his toes. During the full examination, I confirmed and removed a large bindi from his paw. Following removal, he became much more comfortable and was able to walk. I explained to the owner that while the bindi was the cause of his acute discomfort and lameness, the back pain is likely a chronic issue related to his IVDD that requires ongoing management.PLAN:Discharge home. The owner will continue with his existing management plan and will attend the scheduled follow-up appointment with VSS on Friday to reassess his IVDD.For any questions regarding the case, please contact the Underwood and Jindalee Clinical Support Line at 07 3147 8746 (Mon-Fri, 9am-6pm), or our hospitals during after hours.    Vital Signs