C10024256 / invoice 10000

Reason: V2/3 - Poss IVDD  - Delayed CP On LHLPresented and seen by Dr  Michelle Hahm   @ Time/Date 2052 12/3/2026History:Last week noticed that Perry had an "episode" where he appeared more stiff, reluctant to move as much. Sometimes whimpering in pain. O has mentioned that over the last year, have not been able to wean off prednisolone, appears that O has been self-managing and restarting/stopping prednisolone on own accord. Has been off steroids for 2 months, and resumed at 5mg SID for approximately the past week, assuming it was an IMPA flare up.No CSVD, still has good appetite.Occasionally does have defecation issuesHas had a mild stiffness in gait after two spinal surgeriesHas previously been managed for IMPA and SRMA. One time requiring advanced imaging to determine if SRMA flare up vs IVDD.Examination Findings:General demeanour: BARTemperature: 38.2Cardiovascular: no murmur or arrhythmia, FP synchronous and adequate bilaterallyRespiratory:  no overt bronchovesicular sounds, normal effort, no cough/sneeze witnessedAbdomen: soft, doughy abdomen, no pain elicited, no. mass effectPeripheral LNs: WNLEyes/Ears: NSFIntegument: WNLOral exam: NSF Musculoskeletal: comfortable on all ROM of limbs, no swelling over joints, most painful over thoracolumbar spinal palpation, mildly uncomfortable over lumbar region; normal neck manipulation.  Gait: Ambulatory, has a stiff gaitNeurological: Normal mentation, CN normal, CP x 4 intact, VMF intact bilaterallyRectal exam: DNP, normal faeces produced whilst obtaining temperatureMethadone 1.5mg IM Fentanyl 12ug/hour patch placed - remove in 3.5 daysGabapentin 50mg BID PRN for up to 5-7dParacetamol 10mg/kg PO TID PO for up to 5d (paracetamol sheet provided)Prednisolone 5mg - advised to start tapering off over the next week, as currently no evidence of IMPA and seems less likely to be SRMA flare up. To give 5mg every 2nd or 3rd day until stopping.Initial Assessment:Spinal pain - suspect IVDD > SRMA recurrence. Has had previous IVDD surgeries (2x)Previous SRMA Previous IMPAClient Communication: Informed O that it sounds like previous episodes of "flare up" may be more spinal pain releated, not necessarily IMPA or SRMA. The dose O self prescribed with remaining steroids may not be enough - and would not have been long enough to keep things at bay. Not sure how regularly O has been following up each episode with reg vet. Stressed that given in the past, the spinal pain was difficult to ascertain whether if IVDD or SRMA recurrence, O needs to be prepared for advanced imaging over the upcoming few days. If neurological decline or worsening pain, to recheck sooner. Otherwise, recheck recommended in 2-3 days. Plan:Outpatient    Vital Signs    Weight: 5.8;