Vet AI Scribe for Mobile Vet

Bear

Thursday, June 26, 2025 at 4:10 PM

In-home mobile appointment

Subjective

Chief Complaint

Owner reports difficulty rising from the kitchen floor, reluctance to use the back steps, and two episodes in the past month of slipping and being unable to get up without help.

History

• 11-year-old neutered male Labrador retriever.
• On an over-the-counter joint supplement; no NSAID currently and none in the past year.
• Last full physical exam 18 months ago at a clinic. Owner reports he was too stressed there to permit an orthopaedic exam.
• Owner has rheumatoid arthritis and cannot lift him.
• Appetite, thirst and urination unchanged. No coughing. No known trauma.

Objective

Vitals

• Weight: 38.2 kg (body condition 7/9)
• Temperature: 101.4°F
• Heart rate: 92 bpm
• Respiratory rate: 24 breaths/min

Examined on his own bed. No muzzle or restraint required; no handling stress observed, allowing a complete orthopaedic exam.

Home Environment Assessment

• Kitchen and hallway: Polished hardwood with no runners. Both reported falls occurred here.
• Back steps: Four steps, approximately 7.5 inch rise, no ramp, handrail on the opposite side from the dog's usual line.
• Bed: 4 inch memory foam, on the floor, positioned in a draught from the back door.
• Bowls: At floor level.
• Night routine: Sleeps in the kitchen and must cross the hardwood to reach the door.

Physical Exam

• Coxofemoral: Pain on extension bilaterally, range of motion reduced right more than left
• Musculature: Moderate symmetrical atrophy of both thighs
• Stifles: Crepitus on the right; no cranial drawer; no meniscal click
• Spine: No pain on palpation of the thoracolumbar or lumbosacral spine
• Neurologic: Proprioceptive placing intact in all four limbs; no ataxia
• Nails: Overgrown; dorsal surfaces of the left forelimb middle digits worn, consistent with scuffing
• Cardiac and respiratory: No murmur; lungs clear

Assessment

Primary Problem List

1. Bilateral coxofemoral osteoarthritis, right worse than left
2. Right stifle osteoarthritis
3. Overweight — body condition 7/9
4. Environmental hazard — unmodified flooring is the proximate cause of the falls
5. Care gap from handling stress in a clinic setting

Differentials

• Degenerative joint disease (most consistent)
• Lumbosacral disease — less likely given normal palpation and intact proprioception
• Degenerative myelopathy — proprioception is intact, which argues against it
• Neoplasia of bone — radiographs will address this

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Plan

Diagnostics

• CBC and serum biochemistry before starting an NSAID
• Hip and stifle radiographs at the next visit under sedation
• Urinalysis

Treatment / Management

• Analgesia: Carprofen 2.2 mg/kg PO q12h, to begin once bloodwork is reviewed
• Adjunct: Omega-3 fatty acids at a therapeutic joint dose; discuss monthly bedinvetmab as an addition if response is incomplete
• Traction, before medication takes effect: Non-slip runners along the kitchen-to-door route; toe grips or paw traction pads; nails trimmed today
• Access: Ramp for the back steps; raised feeder; bed relocated out of the draught and a thicker orthopaedic bed recommended
• Weight: Measured meals with a target of 34 kg over four to five months; treats accounted for in the daily allowance
• Exercise: Short, frequent leash walks on grass rather than pavement; avoid stairs where possible

Follow-Up

• Bloodwork before the first NSAID dose
• In-home recheck in 3 weeks to reassess once matting and the ramp are in place
• Weight recorded at every visit

Client Communication:
Discussed that the falls are happening on hardwood and are as much a flooring problem as a joint problem — and that because the owner cannot lift him, traction needs to be in place before medication has had time to work. Explained that seeing him at home allowed a full orthopaedic examination that had not been possible at a clinic, and that future orthopaedic rechecks are better done this way. Sedation for radiographs will still require a clinic visit, and a plan for that was agreed.

— Dr. Ruth Anselm, DVM