C10012559 / invoice 10000

HISTORY: Presenting Complaint: Posible IVDD flare up, hind legs giving out/very stiff/sore

History:
OR possible IVDD flare up, left hindlimb hind legs are giving out/very stiff/sore
Left hindlimb.
OR has been at her mother & father in laws toay. 
Had IVDD no problems since then.
Melxoicam usually helps but didn't 
Does run around crazy, odes jump up & down 
Quite 
EDUF normal that O is aware of. 
Current Medications: 1/2 Firborxoc 227mg 8:30am this AM. 

Observation:
EXAMINATION
Demeanour: BAR, CARE** growls, is reactive (OR is a rescue) 
BCS: 6/9
Integument: Left side neck tiny lump, rectum tiny lump 
CRT: unable to assess           
MM: pink/moist 
HR:   BPM,    Rhythm:
RR: panting,  Effort: normal
Temp: NT 
Peripheral LN's: WNL
Abdomen: mildly tense on palpation 
Musculoskeletal: Moderate left hindlimb lameness, minimal/toe touching weight bearing on the limb, no obvious heat or swelling in limb, no reaction to palpation of the entire left hindlimb, no palpable fractures, stifle joint feels possibly effused if anything, stifle joint not obviously unstable, unable to assess cranial draw too tense to feel, minor mid lumbar spinal pain - just slightly dipping back on palpation
Neurological: NAD
Urogenital: NAD
Rectal: NAD

Assessment:
1) Left hindlimb lameness 

Plan: 
1) 1.1mls Buprenorphine injection given SC for pain relief.
2) TGH on Oral Meloxicam 1.1mls SID for pain relief - start tomorrow AM.
3) TGH on Gabapentin 300mg BID for pain relief/mild sedation to keep quiet.
4) TGH on Amantadine 50mg BID for pain relief.
5) Recommended booking in with SFR in ASC for radiographs of left hindlimb & spine.
WEIGHT: 17.10

WEIGHT: 17.20
HISTORY: Reason: COHAT 
PE 
BAR 
anxious 
Pink moist mm crt <2sec RR panting 
HR 100 
dental stage 2-3 

Pre ga medications 
methadone 0.3ml medetomidine 0.07
IV cath placed right cephalic 
IV propfol 4mls 
ET 7.5 cuffed 
Maint iso 


Full oral examination, Complete dental Xrays, scale and polish 
Findings: No oral masses or ulcerations, normal facial; symmetry no nasal discharge. Marked calculous and tartar on teeth, an extra tooth caudal to 110, appears healthy. 

Small dermal pin point lump just below anus. DDX: skin tag, small cyst, new growth, benign or malignant. Options include surgical biopsy, monitoring for changes in size or shape and colour. the mass is too small for a fine needle biopsy. 

If you would  like a biopsy taken of the mass this will include a separate general anaesthetic and surgery the cost estimate is approximately $1500  
7 days recheck 
with Veterinarian 
rest for 24 hrs post anaesthetic         
Monitor For anorexia oral pain coughing vomiting and diarrhoea. To help prevent dental disease regular scale and polishes, teeth brushing, dental cleaning with Maxi guard wipes can help. 



NOTE wastage 0.3ml methadone  was not given two lots i accidentally waisted 0.3mls

HISTORY: REASON – Pre dental

HISTORY - OR had diarrhoea at the start of the week but has come good
OR can be reactive but not usually at the vet 
booked in for dental next week - check up prior today
O has tried plaque off they won't eat it, has oxyfresh at home, has a tooth brush and brushes teeth regularly, dogs won't eat dental chews / hard food etc

Appetite: normal
Water intake: normal
Urination:  normal
Faeces: normal 
Energy levels: normal
Coughing or sneezing: none 
Vomiting: none
Diet: roast chicken, meatballs, sardine, eggs, dog biscuits 
Parasite Control: 
Vaccination status: UTD
Current Medications: none

EXAMINATION
Demeanour: BAR
BCS: 6/9 
Integument: healthy groomed coat 
Eyes: normal
Ears:  normal
Nose:  normal
Mouth:- normal
CRT:  <2 sec         
MM:  pink 
Dental disease: Grade - 1-2/4 - minimal tartar mainly canines and 108 / 208 / 109 / 209
HR: 120  BPM,    Rhythm: no murmur or arrhythmia 
RR:   BPM,    Effort: none
Temp:  not taken 
Peripheral LN's:  normal
Abdomen:  normal
Musculoskeletal:  normal
Neurological:  normal
Urogenital: not assessed
Rectal:  not assessed 

ASSESSMENT:
await preGA bloods

CLIENT COMMUNICATION:
Discuss preGA bloods - discuss good to do before dental if O happy to - O ok to do today
explained tartar on teeth - no obvious extractions needed from look but can change once get rads and we will call on the day with updated price and if needs doing
discussed price for COHAt and extractions with O
discussed blood ok too

TREATMENT:
preGA bloods ran on idexx as heska out of action at present
bloods all normal (mild decrease in alk phos is only abnormality)
Rang O and advised bloods are all ok

PLAN: Booked for 9/2 for dentals

ESTIMATES: $689 for COHAT, $1500-$3000 if extractions (think unlikely though)
WEIGHT: 16.40