C10003536 / invoice 10000

Appointment Notes: whimpering/crying when moving for the past hourHistory:18 month hx of intermittent hesitancy to jump up onto a bed/couch 40-50cm in height. In last 24 hours stepped down from couch to mattress laid on lounge room floor (reducing jump height to 20-30cm) and yelped and has had hunched posture, shaking when using hindlimbs and ataxic gait since. Episodes of pain are usually treated with meloxicam oral liquid for 5-7 days then she recovers.Today, hesitant to walk and yelping in pain, Os carried her into clinic Examination:Demeanour: BAREars/eyes: no discharge, NADOral: mm P&m, CRT <2s, no dental disease evidentHydration: normalL/N: WNLCardiovascular: no murmurs or arrhythmias, HR 86Respiratory: normal lung sounds, RR 36Abdo: not performed as very sensitive in caudal halfUG/rectal: not performed as very sensitiveMsk: hunched posture and whining when taking small steps. yelped on lumbosacral spinal palpation, hesitant to stand and hesitant to full extend hindlimbs backwards, no reaction to palpation of digits or stifles. Tail erectSkin: NADAssessment:ddx spinal injury vs disc protrusion/extrusionTreatment:0.2mg/kg methadone SCmeloxicam PO SID X7dparacetamol 100mg/ml give 4.6mL PO BID X 7dDiscussion with owner:Plan:O to consider outpatient CT     Vital Signs