Instructions: Compose a SOAP. If necessary, refer to your Mc…
Instructions: Compose a SOAP. If necessary, refer to your McCurnin book for instructions regarding SOAP construction. Assessment of the data or assignment of technician evaluations must be based upon the information and data provided. Plans should be both technician and veterinary driven interventions. It is important to recognize that assessment and plan portion of this exercise involves more than a simple categorization of facts. Scenarios typically provide only veterinary driven interventions. Assessments and technician driven interventions must be developed by the student. Subjective Data :(2pts) Objective Data: (2pts) Assessment: (5pts) Plan: (6pts) Lame Dog Scenario: Reki, A one year old spayed female Labrador Retriever was presented with a history of progressive hindlimb lamness. The owner reported that the dog had moved normally until approximately 2 months ago. She now moved with a “bunny hopping gait” and refused to jump into the bed of the pickup. In response to the lameness, the owner had given Reki aspirin for one week. The home treatment resulted in little to no improvement in the condition. Physical examination. Revealed a grade 2/5 Bilateral hind limb lameness which was most apparent When the dog grows from a recumbent position. Deep Palpation of the hips elicited guarding/limb withdrawal behaviors and whining. There was a 20% decrease in coxofemoral joint ROM. No abnormalities were noted during palpation of the stifles or hocks. The dog weighed 85 pounds. BCS Was assessed ay 3.5/5. Based upon clinical findings, the veterinarian requested radiographs of the coxofemoral joint. To obtain quality radiographs, the veterinarian ordered the dog to be sedated using 0.1mg/kg IM metomedine. The technician administered the tranquilizer and took the films. Abnormal radiographic findings included bilaterally shallow acetabulum, short femoral necks and flattened femoral heads. Surgical intervention was recommended. However, the client declined surgery, citing costs as an issue. Thus, medical management was instituted to include a long-term prescription for carprofen 2mg/kg PO BID, ADEQUAN 5mg/kg IM once weekly for four weeks, and a recommendation for weight loss and moderate exercise. The technician dispenses the carprofen, provided instruction regarding medication administration and described how to best manage the pet’s weight issue. The first dose of Adequan was administered by the technician and an appointment was scheduled for the second injection in 7 days.
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