C10028931 / invoice 10000

REASON: Reluctance to walk following routine walkHISTORY: Frankie went for routine 3km walk to playground and back around early afternoon. Owner reports she seemed tired on walk home. Upon returning home at approximately 5pm, Frankie laid down and remained in kitchen area rather than joining family on couch as usual. Demonstrated reluctance to move and vocalised when approached for touching. Owner noted she would not walk over to couch or bedroom as normal, and did not cry to get up on furniture as typical behaviour. When standing, Frankie would remain stationary but showed reluctance to walk.- Access to toxins: No known access to any toxins, bait, rubbish, medications, chemicals nor anything else that could have been scavenged.- Pre-existing conditions: Previous patellar luxation one back leg approximately 3-4 years ago (grade unspecified), resolved with weight loss. Previous episode of reluctance to walk requiring veterinary attention in 2024.- Current medications: nil mentioned- Current vaccination status: up to date- Prophylaxis: NexGard Spectra monthly- Diet: Fed morning and afternoon portionsTRIAGE:- HR: 132 bpm- RR: 20- Temp: 38.1°C- Mm: pink- Crt: <2secs- Mentation: BAR- Pain Scale (0-4): 1- Hydration status (%): normalEXAMINATION:Body Condition Score (1-9): 5Pain Scale (0-4): 1Cardiovascular: Cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: Thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: Proprioception normal, Cutaneous trunci reflex intact bilaterally. Resistance to neck rotation bilaterally (R>L) noted. No other neurological deficits detected.Musculoskeletal: Reluctance to walk but ambulating normally. no lameness. Both patellas securely in groove. no joint swelling or effusions. full ROM in hips and stifles and tarsus.  no pain on spinal or neck palpation but pain/resistance on flexion of neck. Gastrointestinal:- Oral: NSF- Abdominal: NSF- Rectal: not performedUrinary: NSFReproductive (incl ext genitalia): SpayedIntegumentary system: Recent ear infections, skin irritation ventral abdomen with prescribed medication. Matted coat noted. Lymph nodes slightly enlarged.Lymph Nodes: Slightly enlarged on palpationEyes: NSFPROBLEM LIST:1. Mild neck pain 2. Reluctance to walk at home DIFFERENTIAL DIAGNOSIS: Soft tissue injury cervical region. Intervertebral disc disease less likely at this stage due to normal neuro exam.DIAGNOSTICS:Nil performedASSESSMENT: Frankie presented with acute onset reluctance to walk following routine exercise. Physical examination revealed sensitivity in thoracolumbar region with resistance to neck rotation. No neurological deficits detected with intact cutaneous trunci reflexes bilaterally. Stifles stable with no evidence of patellar luxation recurrence. Clinical findings consistent with soft tissue injury or muscle strain in thoracolumbar region. No evidence of intervertebral disc disease given normal neurological status.TREATMENT:Loading dose meloxicam 0.2mg/kg SC administered_Medications:_- Meloxicam oral liquid for 3 daysPLAN:- Strict rest for one week - no walks, no jumping on/off furniture including couch- Monitor closely for any signs of ataxia or paralysis- Return immediately if any neurological signs develop- Follow up if no improvement or worsening of condition    Vital Signs    Weight: 6.6;       

Reason: UnsettledTIME: 2:29HISTORY:Frankie presented this evening for ataxia. She was growling at the owners door to be let in which is normal for her to do. She was sitting at the door and was unable to stand up and walk. She was able to sternalise and put weight on her forelimbs but did not move her hind limbs. Frankie has access to outside during the evening. She has gained weight (now weighs 7.7kgs but is normally about 6.5kgs)Has history of luxating patella in one of her hind limbs (owner believes it is the left)She is on a special diet for her skin and weight. On flea/tick prevention (Nexgard Spectra)No vomiting or diarrhoea. Owners have a 3 week old newborn at home and Frankie has been acting a bit weird since the arrival. Current meds: NoneProphylaxis: UTD Nexgard SpectraPre-existing conditions: Skin allergies, Luxating patellaAccess to toxins eg. Rodenticide: Access to outdoors but no snakes on property (sometimes chases cane toads)TRIAGE: HR: 110RR: 28Temp: Not taken (anxious)Mm: Pink, moistCrt: <2sMentation: BAR, anxiousPain Scale (0-4): 0Hydration status (%): EuhydratedEXAMINATION:Body Condition Score: 6/9Cardiovascular: Cardiac auscultation normal, normal rhythm, pulse pressures normal and synchronousRespiratory: Thoracic auscultation clear sounds bilaterally, respiratory effort normal, no nasal dischargeNeurological: Neurologically no significant findings, no cranial nerve or proprioceptive deficits/gaitMusculoskeletal: Ambulating normally, no palpable neck, spine, limb or joint painGastrointestinal:- Oral: normal, no mouth pain, dental score (1-4):  1- Abdominal: no detectable pain on abdominal palpation- Rectal: not performedUrinary: Small bladder on palpation Reproductive (incl ext genitalia): Normal conformation Integument/Ears: No alopecia or erythemaLymph Nodes: Peripheral lymph nodes normalEyes: Clear and bright bilaterallyPROBLEM LIST: -AtaxiaDIFFERENTIAL DIAGNOSIS/ DIAGNOSIS: IVDD vs Soft tissue injury vs Fracture vs Luxation vs Tick Paralysis vs Snake vs Anaphylaxis vs ToxicityDIAGNOSTICS:Offered owner full bloods and radiographs to rule out fracture. Unable to localise any pain. Owner declined at this stage. TREATMENT:Offered pain relief (NSAIDs) but Frankie was walking well in the consult room and was not painful on physical exam. Gave owner dose of paracetamol (125mgs or a quarter of a 500mg tablet PO Q8) to give at home for pain relief as needed. PLAN:Monitor at homeIf any deterioration, recheck with AES or regular vetCLIENT COMMUNICATION:In consult-Discussed causes for ataxia. Frankie was not painful on physical exam, however offered full bloods and radiographs to rule out causes such as fracture or toxicities or snake evenomation. Owner declined at this stage because Frankie was walking around the consult room and had perked up since arriving. Offered pain relief (NSAIDs) and owner declined at this stage. Will recheck with AES or regular vet if there is any deterioration in the morning.    Vital Signs    Weight: 7.7;