This section should include details of the initial consultation, physical findings, treatment plans/options, admission details (where applicable), diagnosis or differential diagnoses, veterinarian recommendations.
Examples:
Grade: Fail
The initial examination performed by the surgeon revealed a bright dog, with vital signs within normal ranges.
| Normal range | Patient data | |
|---|---|---|
| HR | 60-180 | 104 |
| RR | 10-30 | 28 |
| Temp | 38.3-38.7°C | 38.6 |
| CRT | 1-2sec | 1.5 |
| MM | Pink, moist | Pink and moist |
| LOC | BAR | BAR |
| Hydration | Hydrated | Hydrated |
Assessment of the patient’s posture revealed reduced weight bearing right hind limb (RHL). The surgeon made a differential diagnosis of cruciate injury and that surgery was required.
Grade: Pass
The initial examination performed by the surgeon revealed a bright dog, with vital signs within normal ranges.
| Normal range | Patient data | |
|---|---|---|
| HR | 60-180 bpm | 104 bpm |
| RR | 10-30 bpm | 28 bpm |
| Temp | 38.3-38.7°C | 38.6°C |
| CRT | 1-2sec | 1.5 |
| MM | Pink, moist | Pink and moist |
| LOC | BAR | BAR |
| Hydration | Hydrated | Hydrated |
Assessment of the patient’s posture revealed reduced weight bearing right hind limb (RHL). Palpation of the affected limb revealed there was stifle pain and instability with palpable thickening of the right stifle joint. There was normal to slightly decreased right stifle joint range of motion.
The surgeon made a differential diagnosis of acute on chronic right cruciate ligament rupture and caudal pole tear medial meniscus. The surgeon recommended that a Tibial Wedge Osteotomy is the best option for surgical treatment of stifle instability due to cruciate disease in a dog of the patient’s size and activity level.
Grade: Credit+
The initial examination performed by the surgeon revealed a bright dog, with vital signs within normal ranges.
| Normal range | Patient data | |
|---|---|---|
| HR | 60-180 bpm | 104 bpm |
| RR | 10-30 bpm | 28 bpm |
| Temp | 38.3-38.7°C | 38.6°C |
| CRT | 1-2sec | 1.5 |
| MM | Pink, moist | Pink and moist |
| LOC | BAR | BAR |
| Hydration | Hydrated | Hydrated |
Assessment of the patient’s posture revealed reduced weight bearing right hind limb (RHL). There was a moderate (grade 5/10) RHL lameness. The surgeon palpated all the limb joints and hips, and performed cranial draw test, and tibial compression test. Palpation of the affected limb revealed there was stifle pain and instability with palpable thickening of the right stifle joint. Manipulation was most resented on flexion and extension of the joint and there was normal to slightly decreased right stifle joint range of motion. Other findings included mild peri-articular thickening around the left hock, however there is minimal thickening around the left stifle joint and no palpable pain or instability on this side. The manipulation of the hips and hocks was well tolerated.
The surgeon made a differential diagnosis of acute on chronic right cruciate ligament rupture and caudal pole tear medial meniscus. The surgeon recommended that a Tibial Wedge Osteotomy is the best option for surgical treatment of stifle instability due to cruciate disease in a dog of the patient’s size and activity level. The patient was given a good prognosis for recovery with surgery, however as she is relatively elderly, bone healing may be delayed and a longer period on confinement may be necessary.
The patient was temporarily admitted to the hospital to allow blood samples to be taken for a pre-anaesthetic workup (results are discussed under section titles Pre-Anaesthetic Blood Work). The patient was then booked in for surgery the following week, pending laboratory results.