C09997239 / invoice 10000

Reason: PainHistory:Presenting for assessment of abnormal behaviour - owners think secondary to painPresented by male ownerUnsettled and uncomfortable for the last 24h, a bit lethargic todayPacing around the house, stiff gait, no obvious lameness noticed thoughAlso yelping randomly Owners can't identify painful spots on herUnknown triggerNo known trauma (but goes out in garden unsupervised)No recent changes in diet or environmentNo known access to toxinsNo known scavengerPrevious history- Bilateral cataract surgery- Dental diseaseEating and drinking normallyOwners unsure about urination as she goes outside for thatUTD with vaccinations and preventatives according to male ownerDiet - advanced dry food Current medications/supplements - noneExamination:T 38.7 HR 120 RR 28MM pink, CRT <2secsCOAT/SKIN: euhydrated, clean coat, no obvious skin lesionsEYES/EARS: clear, no obvious discharge or inflammationMOUTH: dental disease grade 3HEART: normal heart sounds, no obvious murmur or arrhythmias, FPSSLUNGS: normal BV sounds bilaterally, no obvious crackle or wheezing, normal respiratory effortABDOMEN/DIGESTIVE/URINARY: soft on abdominal palpation, no obvious organomegaly or masses CNS: BAR, ambulatory, no obvious neurological deficitsMSK: No obvious lameness in consult, no obvious muscle atrophySignificant pain (yelping) on cervical region when mobilising neck laterally (both sides), less reactive with dorso-flexion and ventro-flexionNo obvious discomfort when palpating thoracic and lumbar spineNo obvious abnormalities on hipsGrade 2 MPL on LHL, no obvious crepitus or pain associatedNo obvious abnormalities on RHL or FLsPERIPHERAL LYMPH NODES: wnlBC - 6/9 - overweightLaboratory:CBC - unremarkableChem17 - mildly increased TBIL (suspect artefact from haemolysis, difficult blood draw)Lytes - wnlAssessment:Only obvious finding in PE is cervical pain - soft tissue injury/trauma vs severe OA/spondylosis vs meningitis vs IVDD vs other MSK condition (fracture, luxation, other spinal conditions) vs systemic (metabolic, immune mediated, etc)Open diagnosis at this stageDiscussed assessment as aboveDiscussed trial with conservative management vs referral for reassessment +/- advanced diagnostics Owner elected conservative treatment for nowTreatment:Methadone 0.3mg/kg SCMeloxicam 0.1mg/kg PO SIDGabapentin 50mg/kg PO BID - advised may cause mild sedationStrict restPlan:Recheck if not improving or any deterioration    Vital Signs    

    Vital Signs    

    Vital Signs