C10003103 / invoice 10000

HISTORY: O noted Frankie was having trouble with walking up stairs and jump ytd night after playing with other dog, but no ataxia seen. Overnight when O woke at 1-2 am, heard Frankie walking down stairs and heard him tumble down. Since then o noted Frankie has obvious ataxia seen. Known OA on catrophen, known glucoma of right eye currently on chlorsig. EXAMINATION:Body Condition Score: 5/9Pain Scale (0-4): 0/4Hydration status (%): euhydratedCardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: obvious ataxia on HL left worse then right. Cp delayed bilaterally left worse then right. Petella and siactic reflex present bilaterally. Musculoskeletal: ambulating, no obvious pain felt on spinal palpation. No obvoius pain on neck ROM.Gastrointestinal:- Oral: c1/g1- Abdominal: no detectable pain on abdominal palpation, normal gut sounds- Rectal: no detectable abnormalitiesUrinary: NSFReproductive (incl ext genitalia): NSFIntegument/Ears: NSFLymph Nodes: NSFEyes: NSFPROBLEM LIST:HL ataxiaDelayed bilaterl HL cpDIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:FCE vs IVDD vs ANNPE vs fracture vs mass vs otherDIAGNOSTICS:Blood gas - hyperlactaemia 4.1, hct 55, hypocalcaemia 1.19, hypochloraemia 108-Interpretation - mild dehydrationASSESSMENT:Suspect FCE due to no pain located but cannot rule out other.TREATMENT (Fluid Therapy & Medications refer to Smartflow):Fent CRI 2 ug/kg stopped @ 0700IV Hartmanns fluid maint rate.PLAN:Hosp until VSS transfer.CLIENT COMMUNICATION:Talked to O about ddx, noted at this stage motor function present but marked ataxia, concerns of neurological issue. Gave o opt of conservative treatment vs referral to specialist. O opt for specialsit. Gave o opt of home monitor and book in consult vs hospitalisation and referral directly. O opt for hospitalisation. O understand will be phone consult.    Vital Signs