C10007537 / invoice 10000

HISTORY: No food since 10pm yesterday
No water since 7am
Has urinated and defecated
CLIN_EXAM: BAR
CRT <1
MM - Pink
TPR NAD
TREATMENT: Routine GA as per sheet.
Premed:
Induction:
Maintenance:
IVFT at surgical rates. MAP >60 through out.
Smooth recovery.
Meloxicam  ml given SC during recovery.
E collar placed. Offered food and water.
Discharged with surgery notes. Advised to keep confined.
Revisit in 5 days. SR in 10-14 days
WEIGHT: 39

HISTORY: Previously seen by SL for similar episode
Responded well to treatment at the time 
Went for a walk then tried to get onto the bed and became painful. Cried in pain when o tried to help onto the bed. Has been relucant to climb up onto anything since
CLIN_EXAM: Minimal pain evident on physocal exam today until extended both HLs out behind him to extend the SL joint. Immediately screamed in pain at this. No CP so makes IVDD less likely but warned still possible
TREATMENT: Advised starting with sedation and xrays to assess SIJ 
Warned that if non diagnostic may need CT
DIAG: Sacroiliac joint disease seems mostly likely dt breed

CLIN_EXAM: BAR
CRT <1
MM - Pink
Teeth - Good dentition 
Heart/Chest - Normal auscultation
Peripheral LNs : WNL
Abdomen : Soft comfortable on abdominal palpation 
MSK - Painful on palpation of caudal lumbar region. repeatable
WEIGHT: 37.80
HISTORY: Has been reluctant to jump up into car, on bed ect as of recent > otherwise no clinical signs. 
Spoke with Pet insurance online vet > advised to monitor and rest for a few days. 
Will often go on 5km walk / runs. 
No limping. 
EDUD as normal. 
Adopted at 1 year old > not aware of any injuries prior to adoption.
TREATMENT: Strict rest for 7 days then slowly reintroducing exercise. 
Meloxicam liquid - 2.5ml SID with food for 7 days (O has bottle at home)
If no improvement may consider CT scan / futher imaging.
DIAG: MSK caudal lumbar spine