C10012298 / invoice 10000

WEIGHT: 44.00
HISTORY: Reason:
- Investigation of stiffness and reluctance to move; diagnostic radiographs of stifles and spine.

Objective: Pre GA Check
- Assess readiness for sedation/radiography. No pre-existing conditions documented that would affect anaesthesia.

Vital 
LABORATORY
- Radiographs: left and right stifles, ventrodorsal spine, lateral lumbar spine.

  - Right infrapatellar fat pad: very mild soft tissue opacification.

  - Suggestive very mild early cruciate degenerative change (right).

  - Right femoral head: apparent Morgan's line.

  - Hips: overall appear good.

  - VD spine and lateral lumbar spine: no lesions identified.

TREATMENT
- Premed: Sedation administered at 13:05 — medetomidine 1.1 mL and butorphanol 0.6 mL.

Surgery Details:
- Surgery Started/Finished: Not a surgical procedure; diagnostic sedation and radiographs performed (sedation commenced 13:05).
- Technique: Sedation-assisted radiography of bilateral stifles and spine. No intra-procedural complications reported.
- Anaesthetic Finished: Not mentioned.
- Recovery: Uneventful
- Pain relief: Analgesia recommended/ongoing; .

Plan:
- Conservative management with ongoing analgesia.
- Restrict activity for two weeks then gradual return to normal.
- Re-examine if deterioration or persistent lameness.
- If ongoing signs or deterioration, consider repeat radiographs or referral for CT/MRI of lumbar spine.

WEIGHT: 44
HISTORY: This evening when o's home from work he was not his usual bouncy self.
Seemed reluctant to get up.
O's have recently taken him back from being looked after by someone else.
O's have been walking him daily which he likely wasn't getting before.
Has put on weight recently.
Eating and drinking normally, faeces have been normal.

MM pink, crt<2secs, hr=104 regular beat. RR=24 normal. Mildly tense on abdominal palpation. t=38.1.
When walking is slightly shuffling LHL.
NAD on palpation of spine/flexion-ventroflexion of neck.
Normal righting reflexes Fl's.
Slightly reduced righting reflex RHL, sig reduced righting reflex LHL.
Sore and muscles flinching on palpation of both hips. 
Muscles very tight both HL's. Stifles NAD.

Suspicious hip pain. Was from a back yard breeder. Possible inflamed disc.
Tx - REST. Carprofen 100mg 1 1/2 tabs sid, paracetomol 750mg bid.
Rec schedule hip/spinal rads with Steve next week to check and then discuss ongoing pain/arthritis management if indicated.
Would NOT rec Beransa in a 3 year old.