C10032024 / invoice 10000

Reason: back legs not working properly, lethargic, 17.7kgHISTORY:   Access to Toxins:  Vaccination:  Parasite Prophylaxis:  Pre-existing Conditions:  Current Meds:  EXAMINATION:  Weight:  17.7kg       BCS:  5 / 9 Hydration Status (%):  euhydrated       Pain Scale (0-4):  1 / 4 T: 38.4c         HR: 108bpm         RR: 20brpm          MM: pink moist          CRT:  < 2s    Cardiovascular: no murmurs or arrhythmias audible, SSFP Respiratory: normal respiratory effort, no nasal discharges, normal BV sounds bilaterally on thoracic auscultation  Neurological: mentation = QAR (anxious), appropriate mentation, intermittent reduced CP in left pelvic limb - No circling / head tilt / head pressing / head turn / facial or eyelid droop / tremors  - Palpebral reflex, menace response present bilaterally - Gag reflex present  Musculoskeletal: - Ambulating x4 with slow, stiff gait and subjective mild wide-based stance - no palpable neck or spinal pain - no palpable joint effusion or pain however reduced ROM noted in left coxofemoral joint and right tarsal joint - no pain on palpation of long bones, muscle atrophy noted over bilateral pelvic limbs Oral: no mouth pain, dental score: C2G1 Abdominal: no pain on abdominal palpation, no palpable tympany or fluid wave, normal gut sounds  Rectal: not performed, anal tone present Urinary: NSF Reproductive (incl ext genitalia): NSF Integument/Ears: cutaneous mass over left stifle and left ear Lymph Nodes: peripheral lymph nodes unremarkable on palpation  Eyes: no blepharospasm / chemosis / epiphora / anisocoria / nystagmus / strabismus   PROBLEM LIST: Difficulty Rising Slow and Stiff GaitSubjective Mild Wide-based Stance Intermittent Reduced CP in Left Pelvic Limb Reduced ROM in Left Coxofemoral Joint and Right Tarsal Joint Muscle Atrophy over Bilateral Pelvic Limbs cutaneous mass over left stifle and left ear DIFFERENTIAL DIAGNOSES: DIAGNOSTICS: 1. PT (11-17):    16.2s             APTT (96-116): 112.6s Interpretation: WNL 2. 3. USG: 1.020 ASSESSMENT: Diagnosis Open (suspected DJD vs soft tissue injury vs spinal disease - other possible etiologies unable to be ruled out without imaging) TREATMENT:Methadone 0.3mg/kg SC once @1215MEDICATIONS TO GO HOME:1. PLAN: Discharge for continued home monitoring with oral analgesics and activity restriction. Follow up with primary care vets within 2 - 3 days for progress evaluation +/- further diagnostics, sooner if clinical signs worsen.CLIENT COMMUNICATION:Discussed possible etiologies and clinical exam findings. O elected to trial conservative management and follow up with primary care vets for further diagnostics if clinical signs do not improve.Biochemistry:Interpretation:Bloods were taken for in-house testing:- Please find attached to the patient record.> Biochemistry- Significant findings:Biochemistry:Interpretation:Bloods were taken for in-house testing:- Please find attached to the patient record.> Biochemistry- Significant findings:    Vital Signs    Weight: 17.7;