C10021384 / invoice 10000

Reason: CON1 Dragging Back LegsPresented and seen by Dr  JDA   @ 11/3Regular Vet: moonee valley animal hospPresenting Problem: HL ataxiaHistory:1hr ago noted ataxia. Not noted to be abnormal in any way prior.Walked as normal this AM.EDDU as normal tonight.Not overtly painful to Owner.Defecated on presentation being held at ARH (nervous + spinal).Unsure urination ability.Any current medications: NilAny access to potential toxins?: NoE/D/U/D: Yes, no V+, no D+. Unsure urintion ability. +/-defecation incontinent.Any known conditions: nilDiet: RC dashound dietPreventatives up to date? YExamination Findings:General demeanour: BARTemperature: T: 38.9Cardiovascular: HR: 126bpm, no murmur, SSFP, MM pk/moist, CRT 1s.Respiratory: RR: 24bpm, normal effort, normal BVS on ausc, no crackles/wheezeOral exam: NSFAbdomen: Soft, no pain/nausea, no mass effectPeripheral LNs: WNLEyes/Ears: NSFIntegument: Clean, clearMusculoskeletal: No crepitus, no swelling, no painGait: HL ataxia (spinal/proprioceptive), ambulatory HL paresis (FL as normal).Neurological: Proprioceptive ataxia (CP mild delay), patellar reflex and withdrawals as normal, mild pain on lumbar palpation (¬L1-L3). Pain perception as normal (superficial). Anal tone present.Rectal exam: nsf on rectal thermometerUrogenital: bladder small, not easily expressed (but too small to express easily anyway).Body Condition Score: 4/9Initial Assessment:Hindlimb paresis, ambulatorySpinal lesion; G2Ddx: IVDD >> FCE/fx/neoplastic/osteomyelitits/otherClient Communication:Discussed options and recommendations with O:1) analgesia + strict rest (6+ wks) plan and continue to monitor: ambulation/paresis, urination, pain, other concerns.2) admit for neuro monitoirng overnight +/- analgesia plan and refer to sx if indicated (progressing)3) euthanasiaCurrent problems: Proprioceptive ataxia/HL paresisPrognosis: GoodTreatment: Analgesia (meloxicam 0.1mg/kg PO SID (after 0.2mg/kg loading dose) + gabapentin PRN bid 100mg (less if too sedate) + REST).Plan:Strict rest for next few weeks (ongoing rest for 6+ weeks, but very strict rest in initial weeks.Analgesia plan as dispensed.Monitoring for progression of dz: worsening proprioception/paresis -> if unable to stand/walk, recommend represent for imaging (CT/myelogram - likely requiring admit through ECC and referral to sx)Also monitoring for urination (if not urinationg voluntarily, may require expressing and ongoing mgmt during recovery) and pain (may develpo pain in coming days, or progress at another point during recovery and warrant further analgesia medication).Any other concerns, to revisit (reg vet or ARH).If concerned surrounding progress - ie not improving at all after 2-3 weeks -> recommend sx consult.    Vital Signs    Weight: 7.1;