C09997178 / invoice 10000

NOTES: Reason: Xrays 

Preop check and admit done by:   st       
Fasted since 8pm last night.   Y/N
Last vacc done:       Worming/flea tx last done:    
Consent to PA bloods  Y     
Medications Y           Last dose:    CARPROFEN AND GABAPENTIN LAST MORNING 
Insurance Gap? : Y / N 
(^RAC, RACQ, Petplan not accepted)    
Insurance details on file? Y           
Personal possessions:       lead            
Discharge Time booked (Vet/Vet telemed/Nurse) appt made and confirmed. Time: after 1PM 
Discuss procedure and risks. Consents signed.  Owners name: Elizabeth Harmati

Preop vitals:  
HR: 100bpm no murmur, arrhythmia
RR:  pant                 
Temp:  not taken as nervous ++ but sweet girl

Preop ortho exam: short stiff adducting HL gait, perched sitting squarely with hocks slightly adducted, reluctant to extend both hips L>R today though R was the sore one
CPs wnl, spine comfortable, no pain on manipulation of stifles or hocks

PA bloods: splenic contraction (excitement), otherwise nad

IVC placed R cephalic v.
Anaesthesia: Premed: medetomidine 0.35mL methadone 1.1mL IM - good sed'n      
Induction: propofol 11mL slow IV to effect
Maintenance: Iso/O2 Anaesthetic monitoring form attached. 

Xray Report
Views/Body Part: 3-view pelvis (incl single lumbar spine lat view), 3-view hocks, 2-view stifles
Quality: good
Findings: R hip dysplasia

Medications: 
Post op check:  HR     ,mm       , CRT <2sec, RR          , Temp            , Time to sternal-              Time to standing - 
Recovery summary 3hrs post-op:     /10   (0-10, 10 being excellent)
Photo sent: (inital and time)

Discharge medications: carprofen and gabapentin dispensed Tue, continue with these
dispensed additional carprofen for PRN use once initial course completed

Discharge comments: 

Revisit:

HISTORY: Reason for consult: 

History:
Stumbled after running quite fast. Gave out a massive yelp. Since then (yesterday) not keen on playing with significant right stifle swelling. Jumping caused yelping/whining. Contralateral weight bearing. 

Current medications: Nil
Vacc hx: Up to date
Parasite control: Up to date
Current food: Unchanged

PEx:
Demeanour: BAR
BCS: 4/9
Integ: normal
Oral: mm pink and moist, CRT 1-2s
Lymph nodes: wnl 
Dental disease: 0/4
Ears: normal
Eyes: mild scleral erythema
Nose: normal
CVS: HR 144 and rhythm wnl and no audible murmur
Resp: Lung sounds clear, resp rate 36
Abdo: relaxed and comfortable
MSK: staggering right hindlimb (occasional) with significant lateral stifle effusion. Too excited to assess for cranial draw/tibial thrust. Increased left hindlimb tone. 
Temp=not taken
Pain score: 1-2/4

Problem List:
Right stifle swelling
Intermittent pain
History of significant traumatic event

Differentials:
1. Cranial cruciate rupture
2. Caudal cruciate rupture
3. Severe muscle strain

Assessment: 
Unfortunately when Mila gets too worked up she will jump and exhibit normal activity levels. This makes it difficult to assess her cruciate whilst conscious. However, the history of trauma and the level of stifle swelling gives strong indication for cruciate rupture. As such the ideal approach would involve radiography and assessment of stifle stability under general anaesthesia. Owner is aware of this and is keen to do it but unfortunately her work commitments make an 8am drop off and 5-6pm pick up quite difficult. Additionally, owner says that Mila will not tolerate other people coming to the house and so having someone else transport her is nigh impossible. 

Treatment:
Carprofen 100mg
Gabapentin 600mg

Plan:
Review at end of course. If lameness is still present then imaging is required.
WEIGHT: 35.70

HISTORY: Reason: 
History: BIB 

brought to dog park this morning 6am
does play quite boisterously
playing with other big dogs in dog park 
RFL
O thinks 
cried when lifted into car 
no hx of RFL lameness or other issues in the past 

Current Medications: none 

fed roo meat and biscuits 

Examination: 
Demeanour: BAR, friendly, loves liver treats
BCS: 5/9 
EENO clear, crt wnl
normal bronchovesicular sounds, heart sounds clear, soft comfy on abdo palp
on neck or back pain 
no obvious lameness during consult 
yelped slightly when O tried to lift dog under front chest 
no obvious joint effusions or abnormalities on manipulation of joints or bones 

Assessment: 
s.t. injury 


Plan: 
REST
meloxicam PO SID short course 
revisit if no better
consider rads as next step?
WEIGHT: 35.00