C09999066 / invoice 10000

Reason: Possible OsteosarcomaHistory: Presented for limping on RFL, suspect early osteosarcoma. Owner is keen on advancedimaging and possible oncology referral. Full bloods performed ALP: 1200+CASE SUMMARY:An 11-year-old female Labrador, Villa Reynolds, was presented for a right forelimb lameness of two weeks' duration. Previous history includes a left total hip replacement for hip dysplasia, with known dysplasia in the right hip and arthritis in both elbows. Examination revealed pain on palpation of the proximal right shoulder, crepitus in both elbows and carpi, and reduced carpal range of motion. Review of referring vet radiographs and blood tests showed findings highly suspicious for osteosarcoma, including a possible Codman's triangle on the right forelimb, a suspected pulmonary metastasis, and a significantly elevated ALP with normal other liver parameters. A full-body CT scan was recommended for definitive diagnosis and staging, but the owner declined due to the high likelihood of metastatic disease and poor prognosis. The owner opted for palliative care. Treatment options including amputation, chemotherapy, limb-sparing surgery, and radiation were discussed. The plan is to continue current palliative care with gabapentin and a long-term anti-inflammatory. The owner will monitor quality of life.Presenting complaint:Right forelimb lameness, sudden onset two weeks prior.Suspicion of osteosarcoma.History:History of left total hip replacement for hip dysplasia.Right hip also has dysplasia.Past medical history of arthritis in both elbows.Currently struggling to walk.Previous X-rays and blood tests performed by referring veterinarian.Physical examination findings:Demeanour: Bright, alert, and responsive.HR: Not recorded.Murmur?: Not recorded.Pulse quality: Not recorded.RR: Not recorded.Respiratory effort: Not recorded.Temp: Not recorded.MM: Not recorded.CRT: Not recorded.General exam:Lameness RFL is notableOrthopaedic exam:Both elbows and carpi are creaky on flexion/extension.Reduced range of motion in both carpi.Palpation of the medial aspect of the right carpus did not elicit a convincing pain response but palpable swellingImaging: Rads from RV - query pulmonary osteoma and single cannon-ball met lesion. Elbows - bilat marked elbow OA. RFL - distal query codman triangle medial aspect distal radius. Similarly query codman triangle caudal prox ulnaMedications:Gabapentin 100mg, two to three tablets, three times daily.Long-term anti-inflammatory for the last four years.Assessment:The combination of clinical signs, signalment, elevated bone-specific ALP, and radiographic findings are highly suspicious for osteosarcoma with probable metastasis. Radiographs revealed a possible Codman's triangle on the right forelimb, significant arthritis in both elbows, and a round opacity in the lung fields suspicious for a pulmonary metastasis. Fungal osteomyelitis is considered a much less likely differential diagnosis.Full body CT recommended. Owner Communication: A full-body CT scan was recommended to confirm the primary lesion and stage the disease, but the owner declined due to the high likelihood of metastatic disease and poor prognosis. The owner has elected for palliative care. Survival times with amputation alone (3-4 months) and amputation with chemotherapy (7-9 months) were discussed. Limb-sparing surgery and radiation therapy were also mentioned as possibilities but not pursued. The plan is to continue current palliative care with gabapentin and the long-term anti-inflammatory. The owner was advised the anti-inflammatory may have properties that slow cancer growth. Referral to an internal medicine specialist for bisphosphonate therapy (e.g., Zoledronate) was discussed as an option for pain relief, but this would require a definitive diagnosis. The owner will monitor quality of life and consider euthanasia when appropriate. A report will be sent to the referring veterinarian, Dr. Colleen.Diagnosis:Suspected osteosarcoma with probable pulmonary metastasis.Discharge instructions:Continue palliative care with prescribed medications. The owner will monitor for quality of life and make a decision regarding euthanasia when appropriate.Discharge medications:Continue current medications: gabapentin 100mg (2-3 tablets TID) and long-term anti-inflammatory as previously directed.    Vital Signs    

Reason: RecheckAppointment Notes: MGPlan: Recheck x-ray - no charge. Put leg through ROM under light GARadiology: X-rays revealed good cup and stem integration with no sign of infection, loosening of other complications. There do not appear to be any osteophytes impinging on the femur or interferance between the stem and periarticula tissues. Examination:  The hip was put through an aggressive ROM test with some pain in full extension and full flexion present. There was no interference with the ROM or unexpected stops. The stifle feels normal with no signs of swelling or buttressing. Similarly the hock appears to be normal. Plan:  I would like to try performing regular physio by putting  the leg through a range of motion at home 2 times daily and see if this improves function and reduces irritation around the joint. Recheck in 3 - 4 weeks after this has been implemented to see what effect there is on function.    Vital Signs    Weight: 25.23;       

History: There has been THR LEFT (with revision + 1 yrs) there had been complete resolution until unobserved incident during ball play yesterday. Acute non wt bearing but otherwise well. The lameness is mildly improved overnight. No medication give. Examination:General Appearance: Very well other than PC. BCS 5/9 T 38.1Mentation: NormalOral Cavity: NormalEyes: NormalEars: NormalIntegument: NormalAbdominal Palpation: NormalGIT: normalUrinary tract: normalCardiovascular:  Pulse normal, Auscultation: NormalRespiratory: Normal   Neurological:  NormalMusculoskeletal: There is an intermittent to touch lameness LEFT PL. There are no gross signs of problem. Too reactive to allow ROM CFJ however limb position is normal and trochanteric and femoral palpation normal. Radiology: CT imaging (this was done one year ago) NAD. (however there is significant callibration artifact). Procedure: Sedated examination: There is full ROM, NAD. Assessment: Acute lameness LEFT THR of unknown origin. Concern: Minor displacement or non radiographic disease.Plan: Commence crate confinment and NSAID pending JM review. Client Communication: As above. Phone message will be left for JM to contact client Thursday. Reassessment if signs progress.    Vital Signs