C10007501 / invoice 10000

Reason: O- Painful, V++ Appointment Notes: Special payment terms exist, Overdue remindersHISTORY:Oliver presented for intermittent episodes of screaming in pain, reluctance to move, and behavioural changes.The first episode occurred on Thursday night when he screamed in pain upon moving in his sleep but settled immediately. This recurred on Saturday, where he woke from sleep and showed signs of complete distress. The episodes of screaming in pain occurred at least three times overnight into Saturday. The owner notes that all episodes have occurred when he is asleep, wakes, and then attempts to move.On Saturday morning, he was taken to his primary veterinarian.- A physical examination including palpation and limb manipulation was performed, with no painful reactions noted. He was walking and running normally at that time.- The primary vet administered a Metacam injection for suspected musculoskeletal pain. They advised the owner to monitor for vomiting or changes in defecation, raising concern for a potential obstruction.- The patient had a normal bowel movement on Saturday.Following the Metacam injection, the patient was reportedly much improved on Sunday, and the owners did not administer any further pain relief.Today (Monday), the patient has deteriorated. He has vomited bile. He has become progressively more aggressive since this morning, growling when approached, which is abnormal for him. Tonight, he has been whimpering and appears reluctant to move due to pain. An episode of squealing in pain occurred again this evening.The owner administered a dose of oral Metacam at approximately 3 pm today but reports no noticeable improvement in his signs. He has eaten his breakfast and dinner normally today.The owner has also observed him in a "prayer" position (stretching with his front end down and hindquarters up), which is unusual for him.He has previously been seen for an anal gland abscessHe has otherwise been well He eats a  mixed diet of dehydrated lamb, treats, and satiety food. He has ad lib access to kibble He has had no change in appetite - ate in AM and PM normally today. The owners do not believe he has improved with the meloxicam administered this afternoon Current meds: Metacam orally at 3 pm today.Prophylaxis: UTDPre-existing conditions: History of self-trauma to the anal gland regionAccess to toxins eg. Rodenticide: noneTRIAGE:Temp: 38.1°CMentation: Bright, alert, and responsive, aggressive HR: 128 RR: 28 MM: pinkCRT: <2 secEXAMINATION:Body Condition Score: 7/9Pain Scale (0-4): 2Hydration status (%): hydration clinically adequateCardiovascular: cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal discharge, stertor/boas Neurological: neurologically no significant findingsMusculoskeletal: ambulating normally, no palpable neck, spine, limb or joint pain. Diffiuclt to fully assess for spinal pain as not cooperative patient however none obvious Gastrointestinal:- Oral: normal, no mouth pain- Abdominal: Tense on abdominal palpation, with signs of discomfort and guarding.- Rectal: NSF, gas ++ Urinary: NSFReproductive (incl ext genitalia): entire male, no discomfort on palpation of testes Integument/Ears: NSFLymph Nodes: NSFEyes: NSFPROBLEM LIST:- Intermittent pain - Vomiting bile (today)- Tense and painful abdomen on palpationDIFFERENTIAL DIAGNOSIS/ DIAGNOSIS:Differentials for acute vomiting would include gastric and intestinal causes (eg. dietary indiscretion, foreign body, infectious, inflammatory, neoplastic, or toxic causes), abdominal disorders (eg pancreatic, hepatobillary, or renal disease or peritonitis) as well as metabolic and endocrine disease.- Pancreatitis- Musculoskeletal pain (e.g., intervertebral disc disease)- Gastrointestinal obstruction (less likely given appetite)- Other DIAGNOSTICS:PCV: 52%TP: 60g/LSerum: clearInterpretation: wnl Dog: 37-55%, 50-80g/LCat: 25-45%, 55-85g/LBlood Gas Analysis Results - source: venous (post-sedation)Findings: PCO2: 49, Cl: 108, Lac: 3.6. BE: 3.0 Interpretation: Mild hypoventilation, hypochloridaemia and hyperlactatemia (post stress/sedation) Bloods were taken for in-house testing:- Please find attached to the patient record.> Complete Blood Count- Significant findings: nsf> Biochemistry- Significant findings:ALT 176Radiology : Digital radiography was performed.Thoracic:Extra thoracic structures: no significant abnormalities, skeletal and subcutaneous structures normalDiaphragm: IntactPleural space: No air or fluidLarge airways: Normal, normal dorsal tracheal membranePulmonary: No pathological pulmonary pattern presentCardiac: Normal size and outlineOesophageal: no air or foreign body presentAbdominal:Extra-abdominal structures: no significant abnormalitiesSerosal detail: goodLiver/spleen: normal size and outlineGIT: No obvious radiopaque foreign body, gas dilation of colon and some small intestinal gas (appears non-obstructive)Kidneys:- Left, normal size and outline- Right, difficult to visualise completely- No obvious renolithsBladder/Prostate: bladder present, no obvious radiopaque urolithsInterpretation: gas dilation in colon and some small intestine. No obvious foreign body visible. ASSESSMENT:Oliver presented for evaluation of intermittent episodes of severe pain, vocalisation, and recent onset of vomiting. The episodes of pain seem to be triggered by rising from a resting position. Examination revealed significant abdominal tension and discomfort on palpation. His temperature and vital signs were within normal limits. The history of improvement with anti-inflammatory medication followed by a relapse, combined with the clinical signs of abdominal pain, vomiting, and posturing, makes a musculoskeletal injury a primary differential vs abdominal pathology such as pancreatitis. Musculoskeletal pain, such as from intervertebral disc disease, remains a possibility, as does other causes of cranial abdominal pain. A gastrointestinal obstruction is less likely but cannot be completely ruled out. Full blood testing was unremarkable Abdominal radiographs showed gas dilation of the colon and some of the small intestine however not an obstructive pattern and no evidence of a radio-opaque foreign body. Oliver has been managed for potential gas within the intetines causing discomfort. Musculokeletal pain cannot be ruled out. Oliver was given a maropitant injection and discharged with panadol. Owner to represent if no improvement TREATMENT:Sedation: Dexmedetomidine 3mcg/kg IM Methadone 0.3mg/kg IM Reversal with 0.02mL Atipamazole - Maropitant injection 1mg/kg SC- Panadol 15mg/kg PO BID - TID (owners have at home - advised of specific dose based on childrens panadol 100mg/mL concentration - owners to check concentration of medication they have at home)PLAN:- Home into owners care- Monitor for improvement. If any further vomiting must be represented. If remains painful/any deterioration then to represent for further diagnostics. CLIENT COMMUNICATION:A detailed discussion was had with the owners regarding the patient's clinical signs and the concerning findings on physical examination, particularly the abdominal pain. Differentials such as pancreatitis were discussed, along with other possibilities like back pain or a gastrointestinal issue. The plan for a diagnostic workup including blood tests, X-rays, +/- ultrasound was outlined. An estimate for these diagnostics was provided and approved. The owners have given consent to proceed with the proposed plan. Discussed results of diagnostics. Advised no clear obstruction however discussed potential of gas causing discomfort. Advised on monitoring at home and if no improvement tomorrow must be represented for reassessment. Advised on panadol dose based on 100mg/ml concentration and advised owners to call when home to check dose. Advised if any vomiting with maropitant injection to represent. Owners happy with plan.    Vital Signs