C10007833 / invoice 10000

ARRIVAL TIME:SIGNALMENT: CookieHistory Summary:History of IVDD surgery approximately four months prior (late October). Recovery has been slow. Owner reports reluctance to walk over the last two days. On Friday, Cookie was painful, able to walk but seems not comfortable. Saturday and today - still uncomfortable, no marked deterioration but seems uncomfortable, often sitting down. Eating and toileting normally. Owner administered Gabapentin yesterday, which resulted in marked sedation according to owner so discontinued.TRIAGE:HR: 112RR: pantTemp: 38.0ÇMM: Pink & moistCRT: < 2 secondsMentation: Bright, alert, and responsiveHydration status (%): euhydratedEXAMINATION:Body Condition Score: 5/9Cardiovascular: Cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: Thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: Ambulatory with a hunched posture. Pain over the thoracolumbar spine. CP normal, slightly slower in the left hind limb. Deep pain normal. Anal tone normal. Able to ambulate.Musculoskeletal: Ambulating normallyGastrointestinal:- Oral: NSF- Abdominal: NSF- Rectal: not performedUrinary: NSFReproductive (incl ext genitalia): NSFIntegumentary system: NSFLymph Nodes: WNL on palpationEyes: NSFPROBLEM LIST:1. Spinal painDIFFERENTIAL DIAGNOSIS:Recurrence or progression of IVDD, surgical site inflammation/infection, adjacent disc pathology.DIAGNOSTICS/MANAGEMENT PLANDiscussed conservative management with strict rest and multimodal analgesia. Plan to review Gabapentin dose (currently 100mg TID, potential to reduce to 50mg TID) to reduce sedation. Advised to continue Meloxicam and dispensed another bottle. Discussed the option of adding a Fentanyl patch for severe pain. Advised that if signs worsen (e.g., non-ambulatory, loss of leg function), urgent re-assessment and referral back to the veterinary specialist (VSS) would be required. Discussed that a specialist would likely only see on a Sunday if surgery was being considered.PLAN:Discharge home for strict cage rest and medical management. Owner to monitor closely for any deterioration in neurological status and contact us or VSS if concerned. Continue Meloxicam and adjust Gabapentin as discussed (50mg tablets dispensed).    Vital Signs