Patient Details. Date/Time Weight (kg) Temp( F) Heart Rate Respiratory Rate BCS Pain Attitude :30:22pm /9.

Transcription

1 Artemis Veterinary Emergency & Specialty Services 7951 Gainsford Court Bristow, Virginia, Ph Fax CLINICAL SUMMARY Animal No Clinical No Record Date Attending Vet(s) Dr Xenia D Newland Referring Vet Dr Katherine Fuller Referring Clinic Morganna Animal Clinic Printed At Printed By Vet Assistant Client Details Patient Details Name Address Perry, Lauren 8776 Tomislav Street Manassas, Virginia, Phone Name Species Breed Joodles Canine Labrador X Age 10 years 2 days Sex Female Spayed Referral Morganna Animal Clinic - Morganna Animal Clinic Health Status Date/Time Weight (kg) Temp( F) Heart Rate Respiratory Rate BCS Pain Attitude 4:30:22pm /90 3/4 QAR Presenting Problem Injured back right leg Exam 1 History 4:25:09pm, Dr Xenia D Newland What symptoms: Not placing any weight on the right rear leg Duration of symptoms: Current diet: Within the last 2-3 hours Taste of the wild, grain free Diet changes/indiscretion: Previous medical problems/current medications: Left cruciate ligament rupture (2017) - medical management Previcox (227mg): 1/2 tab PO around 1pm Vaccines last received: UTD Activity level: Decreased Environment (indoor/outdoor): Fenced yard Was at doggy daycare/boarding and picked up this morning Owner reports that the pet was running around earlier today after being picked up from doggy day care This afternoon was slow to get up for her walk around 1pm Then later was not able to get up and walk When she did stand she would not place any weight on the right rear leg

2 Physical Exam 4:23:01pm, Dr Xenia D Newland EENT: no ocular discharge OU; ears clear AU; nares clear bilaterally; MM pink + moist; CRT <2s PLN: nsf CV/R: nsf; no m/a ausculted, pulses s/s, normal bronchovesicular sounds in all quadrants, eupneic MS/axial: no pain on spinal palpation; epaxial mm adequate + symmetrical MS/appendicular: non-ambulatory - non-wb lameness on PL; significant pain response on palpation + flexion/extension of R stifle; mild joint effusion noted at R stifle; unable to extend hips (d/t pain); full MSK exam not performed Neurological: no deficits noted CP + x 4, CNN nsf, mentation appropriate Abdominal exam: comfortable on palpation - smooth intestines, no palpable FB/mass effects Integument: nsf Rectal exam: not performed Hydration: appropriate Assessments 4:22:29pm, Dr Xenia D Newland R PL - non-wb lameness, pain response on R stifle palpation + flexion/extension DDx: bone injury (eg fx, dislocation, OSA) vs ST injury (eg mm/tendon/ligament sprain/strain) vs other Historical: CCL (L PL) - medical mx Plans 4:21:15pm, Dr Xenia D Newland Advised O that non-wb lameness can be d/t bone injury (eg fx, dislocation, OSA) vs ST injury (eg mm/tendon/ligament sprain/strain) vs other Discussed that diagnostics include X-rays of limbs to look for bone changes Mx depends on dx results RECOMMENDATIONS: DIAGNOSTICS: Pain medication: O approved RADs (PL): O approved Meds tgh: O approved RADs - PL/pelvis LAT: R stifle - mild OA changes (proximal tibia); L stifle - scar tissue VD: R coxofemoral joint - significant OA changes (femoral head + acetabulum) FURTHER ASSESSMENT: R stifle: mild OA changes at proximal tibia R coxofemoral joint: significant OA changes at femoral head + acetabulum L stifle: evidence of scar tissue formation FURTHER RECOMMENDATIONS: Meds tgh: O approved Sx consult: O declined at this time Discussed X-ray findings w/ MR/MRS Advised that evidence of OA changes in both stifles + R hip Discussed that CCL injury +/- OA changes causing discomfort Discussed sx option vs conservative mx O opted to try oral pain meds + adjunctive therapies (eg acupuncture, hydrotherapy, laser therapy); Joodles has had laser therapy on L PL previously THERAPEUTICS: Buprenorphine: 03mg IV once Effect: mild sedation; improved comfort level

3 DISCHARGE: Gabapentin: 300mg PO q8-12h Previcox: continue as previously prescribed by pcvet (*O to contact pcvet tomorrow AM to organize refill of medication) Restricted activity - short leash-walks only +/- sling support (eg Helpemup Harness); no strenuous activity; no stairs/high furniture Adjunctive therapies - eg laser therapy, hydrotherapy, acupuncture Monitor: v/d, lethargy, inappetence, on-going/increased discomfort - contact us or pcvet if concerned If wish to pursue sx consult: can contact us at any time to organize consult w/ Dr Nicholson Diagnostic Request 5:20:02pm, Dr Xenia D Newland Radiographs (2 view) Artemiss Vess In-House Labs Medication Date/Time Drug Name Qty Instructions Prescribed By 5:19:31pm 5:19:31pm Buprenorphine (Buprenex) 03mg/ml injectable [ciii] Gabapentin 300mg capsule 1 42 GIVE 1 CAPSULE BY MOUTH EVERY 8-12 HOURS (TWO TO THREE TIMES DAILY) FOR PAIN MAY CAUSE SEDATION Dr Xenia D Newland Dr Xenia D Newland Client Communication :25:56am Kim Hill called and spoke with the owner who reports that the pet is doing better today and seems more comfortable on the medication She drank water this morning and has a follow up with the rdvm this evening kah Discharge Summaries 5:20:39pm Problem List: Discharge Instructions for: Joodles Perry Right hind-limb: acute onset non-weightbearing lameness & knee pain - underlying diagnosis open: suspected cranial cruciate ligament injury (acute vs partial rupture) +/- meniscal injury +/- osteoarthritis vs other Left hind-limb: cranial cruciate ligament injury (historical) Brief Summary: Joodles presented for an acute onset non-weightbearing lameness in the right hind-limb after running around in the yard today Upon presentation, her vital parameters were within normal limits Her physical exam findings identified significant pain on palpation and flexion/extension of her right knee and a reluctance to weight-bear on the limb Full evaluation for laxity in the right knee was not possible given how anxious she was (unable to elicit cranial drawer sign) We administered an opiate pain medication (buprenorphine) to help make her more comfortable X-rays of her hind-limbs were performed which identified mild osteoarthritic changes in the right stifle, significant osteoarthritic changes in the right hip and evidence of scar tissue formation in the left knee We discussed conservative medical management including strict rest and oral pain medications vs surgical management Further information on Cranial Cruciate Ligament Disease can be found at If you wish to organize a consult with our veterinary surgeon Dr Nicholson, this can be organized here for you at any time Additional adjunctive therapies such as laser therapy, hydrotheraphy and/or acupuncture may help to keep Joodles more comfortable

4 Joodles is going home with an oral pain medication (gabapentin) to keep her more comfortable and she should have her Previcox refilled at your primary care veterinarian Joodles must have restricted activity for at least the next two to four weeks to avoid further exacerbation of her knee injury Joodles may require sling support to urinate/defecate and/or you may consider a harness for support (you can find these at Please continue to monitor Joodles closely for lethargy, inappetence, vomiting, diarrhea, on-going/worsening discomfort and/or other abnormal signs and contact us or your primary care veterinarian if you are concerned Instructions: Monitor Joodles very carefully for the next day and set up an appointment with your primary care veterinarian in 1-2 days if she has not entirely returned to normal; sooner if you have concerns that she is not doing well You should monitor for signs of lethargy, inappetence, vomiting, diarrhea, on-going/worsening discomfort, or any other concerning signs Please contact us right away if you are worried about anything Feed Joodles her normal diet, tempting to eat if necessary Allow access to water at all times Joodles must be kept quiet for the next two to four weeks No running, jumping or playing Avoid stairs and jumping on/off high furniture Crate-rest or pen confinement is recommended Short leash-walks only with sling support to urinate/defecate outside is recommended If she is doing well at the end of that period, you may slowly resume the normal activity level Medications: The following medications have been prescribed for Joodles: Drug Name Buprenorphine (Buprenex) 03mg/ml injectable [ciii] Gabapentin 300mg capsule Instructions *GIVEN IN HOSPITAL This is an opiate pain medication May cause increased panting, salivation and/or sedation This should be effective for the next 8 to 12 hours Please keep Joodles away from stairs and/or high furniture on which she may injure herself further GIVE 1 CAPSULE BY MOUTH EVERY 8-12 HOURS (TWO TO THREE TIMES DAILY) FOR PAIN MAY CAUSE SEDATION *This can be started tomorrow morning Previcox: Please contact your primary care veterinarian to organize a refill of this medication Joint supplements (eg Cosuquin, Dasuquin): You may wish to start Joodles on joint supplements as these have been found to improve joint health Please give all medications as directed Please do not give any additional medications unless directed by a veterinarian Joodles's well-being is very important to us, and we have enjoyed caring for her here at Artemis Veterinary Emergency and Specialty Services If you have any questions or concerns, we would like to know as soon as possible There are no bad questions when it comes to Joodles's care! It is important for you to call your primary care veterinarian with an update on Joodles Your veterinarian will receive a copy of the medical records, with a clinical summary, based on their preference of either fax or Sincerely, Dr Xenia D Newland I, Lauren Perry, have received, reviewed and completely understand any and all dispensed medications and instructions for Joodles I understand the treatment options that were offered to me and have had any questions regarding my choices answered Owner/Authorized Agent Signature:

5 Witnessed by: Vet Communication 7:15:01pm, Artemis Veterinary Emergency & Specialty Services 7951 Gainsford Court Bristow, Virginia, Ph: Fax: Date: We are contacting you in reference to a mutual patient, Joodles Perry You will find attached an update on Joodles as well as all communications that we have had with the owner over the last 24 hours If you have any questions or concerns please do not hesitate to contact us Sincerely, Artemis Veterinary Emergency and Specialty Services We now have Veterinary Surgery and Internal Medicine specialists on staff! Please find attached the clinical summary for Joodles 5:38:15pm, @rcfaxcom Artemis Veterinary Emergency & Specialty Services 7951 Gainsford Court Bristow, Virginia, Ph: Fax: info@artemisvesscom

6 Date: We are contacting you in reference to a mutual patient, Joodles Perry You will find attached an update on Joodles as well as all communications that we have had with the owner over the last 24 hours If you have any questions or concerns please do not hesitate to contact us Sincerely, Artemis Veterinary Emergency and Specialty Services We now have Veterinary Surgery and Internal Medicine specialists on staff! Please find attached the clinical summary for Joodles