C10004544 / invoice 10000

07/02/2026 HISTORY
Presenting for: 5.9kg male poodle cross presenting for intermittent pain episodes, particularly when being picked up or changing positions.
Historical Conditions: 
- Initial pain episode in December 2025 after playing with another dog. Seen at Petstock Dural for this. Bloodwork performed there showed low phosphorus, ALP, and amylase; normal red and white cells; normal kidney function. Treat with Gabapentin and Butorphanol (injection). O stopped after 5d as seemed better
- Recent recurrence of pain episodes over past 2 weeks with no obvious trigger
Diet: Dry food with occasional chicken and vegetables
Current Meds: 
- Not on any regular medication for pain (forgot to check re supplements and preventative medications). Still has some Gabapentin at home, not currently using. Owner applies dental gel daily to teeth.
Lifestyle Risk Factors: 
- Regularly jumps onto and sleeps on elevated surfaces (bed, couch).

EXAM
Mentation: BAR
Wt: 5.9kg
BCS: Good, ribs palpable with gentle pressure
T: 39.1°C
HR: 132
MM: pink
Hydration: moist
Behavioural: Mildly anxious, refused treats
Eyes: Normal
Ears: Normal
Nose: Normal
Throat: Normal
Oral: Mild dental disease noted on canines, incisors, and caudal teeth noted with blue dental light
Cardiovascular: Normal pulse
Respiratory: Normal 
Abdominal: Normal on palpation
Lymph Nodes: Normal
Integumentary: Normal
Neurologic: Normal
Musculoskeletal: Stiffness noted on right hip compared to left. Normal stifles. No luxation noted.
Urogenital: Normal
Rectal: Anal glands were expressed yesterday by owner, were quite full

ASSESSMENT
Back pain - DDx: intervertebral disc disease, musculoskeletal strain
Right hip discomfort - DDx: possible mild hip dysplasia

PLAN
New Meds/Tx:
- Use Gabapentin as needed when pain episodes occur; start if experiencing >3 episodes in one day or more than two episodes over three days. If started then use twice daily for 5 days
- Paracetamol 60mg (1/2 of 120mg children's chewable tablet) PO up to TID as needed if Gabapentin alone is insufficient after 2 hours; can be given in addition to Gabapentin

Changes to Existing Meds/Tx:
- Continue dental gel application daily, focusing on gum line at canines and incisors

Additional Discussion:
- Restricted activity recommended for 6 weeks to allow recovery
- Leash walks 10-20 minutes permitted
- No jumping, ball play, frisbee, or leaping onto furniture
- Proper lifting technique demonstrated: support both chest and pelvis when lifting to reduce strain on back
- X-rays not recommended at this time unless symptoms worsen or fail to respond to treatment
- Monitoring for worsening signs: dragging feet, reluctance to move, unsteadiness, wobbling, lameness to return for further ix if that occurs
- Imaging options discussed: X-rays (50% chance of visualization), CT or MRI better for disc issues but more expensive

Client Comms:
- If symptoms worsen or don't respond to conservative management, imaging may be necessary
- Call clinic for additional medication if needed (neurontin or NSAIDs can be dispensed without visit if seen within 6 months for same condition)