Species: dog
Breed: Bergamasco Sheperd
Sex: m, not neutered
Weight: 25.3 kg
Birth date: 2023-03-22 00:00:00
Primary diagnosis: Unknown trauma with pneumothorax on both sides, pain in the right hip, lameness of the left hind limb, ataxia of both hind limbs
Situation: emergency follow-up
Time since surgery: 0-2 hrs
Medical history: The dog was presented to our clinic on 16.12.2024. Basco is a 1.5 year old male not neutered Bergamasco sheperd dog, who was presented in the emergency department due to an acute lameness after unknown trauma. Yesterday at noon (15.12.24), Basco was walking with his owner in the forest like every day, he ran (as he often does), but this time he did not come back to the owner's call (normally he comes back very well to the call of his owner's path, and if he gets lost, he knows how to get home by himself). The owner searched everywhere for him and found him this morning in the woods, he saw him in the distance and called for him, Basco looked but didn't move. He was screaming in pain and didn't want to get up. So the owner carried him to the car and then came straight here to the clinic in Bern. In the A-FAST a bilateral pneumothorax was seen so the air was punctured two times before putting a drainage, as air continued accumulating. X-rays of the thorax and pelvis were taken. First thorax x-rays report (16.12): Mild to moderate pneumothorax, suspected slightly worse on the left --> There are no radiological signs of blunt trauma or rib fracture to explain the pneumothorax; A ruptured bullae cannot be ruled out. Second thorax x-rays thorax (16.12): Persistent but regressive mild pneumothorax, accentuated left; Left and right hemithorax thoracic drains in place. Pelvis x-rays report (16.12): Normal pelvis --> No radiographical evidence of pelvic fracture or other trauma associated lesions. At the clinic, chest drains were placed to allow continuous suctioning of the pneumothorax. Several orthopaedic, neurological and imaging examinations revealed no specific abnormalities. An analgesic plan was drawn up to control Basco's pain in the back as well as possible. Over the course of his hospitalisation, the pneumothorax regressed and the pain subsided. Third thorax x-rays report (18.12): Regressed and almost resolved pneumothorax; Left thoracic drain in place; Right thoracic drain far ventrally --> If there was no evacuation of air between the two studies there is no longer production of pneumothorax. On 19.12 the thorax drains were taken out.
Medication: No medication before presentation and observation 1. Before observation 2: Methadon 0.2 mg/kg IV. Before bservation 3: Gabapentin 8 mg/kg PO. Started continued aftero observatin 3: Methadon 0.2 mg/kg IV q4h, Ondansetron 0.3 mg/kg IV TID, Gabapentin 8 mg/kg PO TID, Paracetamol 10 mg/kg IV TID. 17.12 (only Meloxicam started after observation 4, the rest already given): Methadon 0.2 mg/kg IV q3h, Ondansetron 0.3 mg/kg IV TID, Gabapentin 8 mg/kg PO at 09 and 12 mg/kg PO at 21, Paracetamol 10 mg/kg IV TID, Ketamin 1 mg/kg SC q4h, Meloxicam 0.2 mg/kg IV, Ropivacain 1 mg/kg per side in the thorax drains q6h, Prokolin 5 mlPO BID. 18.12: (nothing given before observation 5): Methadon 0.1 mg/kg IV q4h, Ondansetron 0.3 mg/kg IV TID, Gabapentin 8 mg/kg PO TID, Paracetamol 10 mg/kg IV TID, Prokolin 5 ml PO BID, Fortiflora 1 bag PO BID, Maropitant 1 mg/kg IV SID, (1x Metamucil 2 tablespoon PO on the food but not eaten). 19.12 (only Buprenorphin and Fortiflora not given before observation 6): Ondansetron & Gabapentin & Paracetamol & Prokolin & Fortiflora same as 18.12, Buprenorphin 0.015 mg/kg IV TID, Metamucil 2 tablespoon PO on the food BID.
Pain type: acute, inflammatory, somatic
Pain origin: pelvis, hind legs
Pain duration: Less than 24 hours
Estimated pain severity: 39