Veterinær AI Scribe til Akut

Joey

Sunday, August 3, 2025 at 11:18 PM

Subjective

Chief Complaint

Joey, a dog, presented for a follow-up appointment regarding chronic rhinitis and a new issue with limping.

History

• Bloodwork from April was normal.
• History of dental surgery with no adverse reactions to carprofen.

Additional History

• History of chronic rhinitis, which improves in winter and worsens in summer.
• No current medications for rhinitis.
• Previous trial of antihistamines, but specific medications not recalled.
• Owner reports frequent but not constant nasal discharge, mostly clear, occasionally yellow, but not green.
• No difficulty breathing except when congested.
• History of vomiting and aspiration in the past.
• Owner reports improvement in symptoms after daily walks and sneezing episodes.
• New concern of limping on the left front leg, which started suddenly after running on stones.
• Owner observed difficulty in Joey bearing weight on the affected leg at home.

Objective

Vital Signs

• Temperature: No fever noted.
• Weight: WNL
• Heart Rate: WNL
• Respiratory Rate: WNL
• Capillary Refill Time: WNL
• Body Condition Score: BCS 4-5/9

Physical Exam

• Eyes: Clear with no discharge
• Ears: Clean with no discharge or erythema AU.
• Oral: Teeth clean, no gingivitis or tartar.
• Cardiovascular: Heart murmur noted, consistent with previous findings.
• Respiratory: No difficulty breathing noted; occasional coughing and postnasal drip discussed.
• Abdominal: No organomegaly or mass effects. No pain on palpation.
• Lymphatic: No peripheral lymphadenopathy.
• Coat and Skin: Multiple small lumps noted, including one on the left front leg.
• Musculoskeletal: A small, mobile lump on the left front leg palpated. No significant pain response noted during palpation.
• Neurological: Normal neurologic exam with normal mentation. No proprioceptive deficits or overt ataxia; normal cranial nerve exam.
• Neck and Thyroid: Neck palpation did not elicit discomfort.
• Reproductive and Urinary: Normal external genitalia, no discharge or inflammation.
• Mammary: No significant findings
• Rectal: Not examined

Assessment

• Chronic rhinitis, likely exacerbated by seasonal allergens.
• Possible soft tissue injury in the left front leg causing limping.
• Small lump on the left front leg, likely a fatty tumor but not definitively diagnosed.
• History of heart murmur, stable.
• No systemic signs of infection or severe illness.

Plan

• Prescribed Rimadyl (carprofen) for 5-7 days to manage inflammation and pain related to the limping.
• Strict rest for a few days to allow for soft tissue healing.
• Monitor the lump on the left front leg for growth or changes; biopsy if it enlarges or changes in character.
• Suggested over-the-counter Zyrtec (30 mg once daily) for rhinitis, ensuring it does not contain decongestants.
• Suggested over-the-counter omeprazole (20 mg twice daily for one week, then once daily) if symptoms of GERD are suspected.
• Monitor for any worsening symptoms, including lethargy, difficulty breathing, vomiting, diarrhea, or changes in appetite.
• Follow-up if symptoms persist or worsen, with potential imaging (x-rays) if limping does not improve.
• Owner advised to discontinue Rimadyl and contact the clinic if adverse effects such as vomiting, diarrhea, or black stool occur.
• Continue monitoring nasal discharge and overall condition.

Client Discharge Note

Thank you for bringing Joey in today. It was great to see her again, and we appreciate your trust in her care.

Summary

Joey was evaluated for her chronic rhinitis and a recent issue with limping on her left front leg. She also has a few lumps that were assessed during the visit. Overall, Joey appears to be in good spirits, with no fever, lethargy, or significant discomfort noted during the examination. Her nasal discharge is mostly clear, with occasional yellow tinges, and her appetite and energy levels remain normal. The limping may be related to a soft tissue injury, as no significant pain or obstruction was identified in the leg. The lumps appear benign but will be monitored for any changes.

Key Topics We Discussed

• Medications:

  • Rimadyl (Carprofen): Administer as prescribed for 5-7 days to manage inflammation and discomfort. Monitor for any side effects such as vomiting, diarrhea, black/tarry stool, or decreased appetite. Discontinue and contact us if any adverse effects occur.
  • Zyrtec (Cetirizine): 30 mg once daily to help manage rhinitis symptoms. Ensure the product does not contain decongestants.
  • Omeprazole (Prilosec): If needed, administer 20 mg twice daily for one week, then reduce to once daily. This may help if GERD or acid reflux is contributing to her symptoms.

• Activity: Restrict Joey's activity for a few days to allow her leg to rest and recover. Avoid strenuous exercise or activities that may aggravate the injury.

• Monitoring:

  • Keep an eye on Joey's nasal discharge. If it becomes green, thick, or if she develops difficulty breathing, please contact us immediately.
  • Monitor her lumps for any changes in size, shape, or texture. If they grow or change significantly, we may need to biopsy them.
  • Watch for any worsening of her limping or signs of pain. If her condition does not improve or worsens, we may need to perform imaging to investigate further.

• Additional Care:

  • Consider bringing Joey into a steamy bathroom during showers to help open her airways.
  • Continue her daily walks, as they seem to help with her nasal symptoms.

• Follow-Up:

  • If Joey's limping persists or worsens, please schedule a follow-up appointment for further evaluation, including potential imaging.
  • Contact us if you notice any new or concerning symptoms.

Thank you for entrusting us with Joey's care! Please do not hesitate to contact us if you have any questions or concerns.

• Dr Moki Griffie