Vet AI Scribe for Orthopedic

Ginny

Monday, August 3, 2026 at 11:13 PM

Subjective

Chief Complaint

Ginny, a 14-year-old hound dog mix weighing approximately 50 pounds, presented for her initial rehabilitation appointment.

History

• Endoscopic biopsies pending from San Francisco Animal Medical Center.
• Previous chest x-rays performed before colonoscopy.
• X-rays also performed at SF Pet Hospital.

Additional History

• Poor appetite recently improved with prednisone and appetite stimulants.
• Awaiting endoscopic biopsy results from San Francisco Animal Medical Center to confirm potential small cell lymphoma.
• History of mobility issues, particularly in the right rear leg, exacerbated after discontinuing anti-inflammatories.
• Appetite has significantly improved on prednisone, with Ginny eating nearly normal amounts and even consuming previously refused kibble.

Objective

Vital Signs

• Weight: Approximately 50 pounds.
• Body Condition Score: BCS 4-5/9

Orthopedic

• Function of all 4 Limbs: Shifting weight to the left side; difficulty sitting and standing; able to stand on both rear legs but offloads weight.
• Strength of all 4 Limbs: Weakness in hamstrings and quads, particularly on the right rear limb.
• Posture: Extended right rear leg when standing; sits with legs not square, indicating weakness and discomfort.
• Palpation - Left Pelvic Limb: Mild muscle weakness; fails the flip test less often than the right leg.
• Palpation - Left Thoracic Limb: Normal range of motion observed; stiffness noted in the front shoulders.
• Palpation - Right Pelvic Limb: Marked muscle weakness; fails the flip test consistently; less muscle in hamstrings and quads compared to the left. Right leg extended when standing.
• Palpation - Right Thoracic Limb: Normal range of motion observed; stiffness noted in the front shoulders.
• Spine: Rigidity in the shoulders and cervical spine noted, likely due to arthritis. Possible lumbar spine arthritis based on posture and history.

Assessment

• Suspected small cell lymphoma pending biopsy results.
• Cervical spine arthritis contributing to rigidity in the shoulders and front legs.
• Lumbar spine arthritis suspected, potentially from prior trauma.
• Muscle weakness in the right rear leg, likely due to nerve compression and disuse.
• Improved appetite and mobility on prednisone, though side effects (panting, increased urination) noted.
• Potential osteoarthritis in multiple areas, including the lumbar spine and neck.

Plan

• Continue prednisone as prescribed, tapering to 20 mg on Monday and then to 10 mg.
• Increase Adequan injections to weekly for joint support.
• Begin Mayo's canine muscle-building formula when available; in the interim, add hard-boiled or soft-boiled eggs to meals for protein support.
• Practice assisted sit-to-stand exercises using a pillow for support and cookie stretches to improve neck mobility.
• Avoid water treadmill therapy for now; focus on land-based exercises such as stepping over obstacles and placing front paws on curbs to shift weight to the rear legs.
• Use yoga mats or rubber flooring to provide traction and prevent injury on slippery surfaces.
• Acupuncture performed today targeting cervical arthritis, for pain management and relaxation; follow-up session after biopsy results.
• Explore the use of Librella (monoclonal antibody for osteoarthritis) after tapering off high-dose steroids and assessing baseline condition.
• Use a heated pillow for morning stiffness in the neck and shoulders.
• Review previous x-rays for cervical and lumbar spine evaluation.
• Await biopsy results to determine if additional treatment (e.g., chlorambucil) is necessary for small cell lymphoma.

Home Exercise Program

1. Assisted sit-to-stand
   • Repetitions: 10
   • Sets: 2
   • Frequency: twice daily
   • Notes: Use a pillow behind her to assist her in sitting without going all the way down. This helps strengthen her hamstrings. Ensure good traction on the floor.
2. Cookie stretches (neck stretches)
   • Repetitions: 3 to each side
   • Sets: 2
   • Frequency: twice daily
   • Notes: Lure her with a treat to encourage her to bend her neck side to side. This helps exercise her neck muscles.
3. Paws on curb
   • Repetitions: hold 10 seconds, repeat 5 times
   • Sets: 1
   • Frequency: once daily on walks
   • Notes: While on a walk, have her place her front paws on a curb and stand there. This shifts her weight to her back legs and helps strengthen her hamstrings.
4. Stepping over obstacles
   • Repetitions: 5–10 obstacles
   • Sets: 2
   • Frequency: once daily
   • Notes: Encourage her to step over small obstacles to improve mobility and strength. Ensure she is not overwhelmed and keep the exercises light.
5. Skin rolling
   • Repetitions: 1–2 minutes per area
   • Sets: 1
   • Frequency: once or twice daily
   • Notes: Gently lift and stretch the loose skin on her shoulders to help relax tired muscles and reduce twitchiness.

Client Discharge Note

Thank you for bringing Ginny in today for her initial rehab appointment. It was a pleasure to meet her and work with her.

Summary

Ginny is a 14-year-old hound dog mix weighing approximately 50 pounds. She has been experiencing a poor appetite and was recently started on prednisone and appetite stimulants while awaiting biopsy results to determine if she has small cell lymphoma. Her appetite has significantly improved on the prednisone, and she is eating well. She also has a history of mobility issues, including muscle weakness and arthritis, particularly in her shoulders, neck, and lumbar spine. Today, we performed an acupuncture session targeting her neck arthritis and discussed a comprehensive plan to support her mobility and overall health.

Key Topics We Discussed

• Medications and Supplements:

  • Continue prednisone as prescribed (currently 30 mg daily, tapering to 20 mg on Monday, and then to 10 mg).
  • Increase Adequan injections to a weekly dose to support joint health.
  • Start Mayo's canine muscle-building formula when available. In the meantime, you can add hard-boiled or soft-boiled eggs to her meals to support muscle development.

• Dietary Recommendations:

  • Continue feeding her foods she enjoys, such as chicken and chicken-based treats.
  • Consider adding eggs to her meals for additional protein.

• Exercises:

  • Practice assisted sit-to-stands using a pillow to support her and strengthen her hamstrings.
  • Perform cookie stretches to encourage neck mobility (side-to-side stretches using treats as a lure).
  • Encourage her to place her front paws on a curb or low surface during walks to shift weight to her back legs and build strength.
  • Avoid intensive physical therapy or water treadmill exercises for now, as she is still recovering and adjusting to her current medications.

• Environmental Adjustments:

  • Ensure she has good traction at home by using yoga mats or rubber flooring in areas where she spends time.
  • Raise her food and water bowls to make eating and drinking more comfortable.
  • Use a heated pillow or heating pad on her neck and shoulders in the mornings to relax her muscles.

• Future Plans:

  • Await biopsy results from Dr. Moretsky to determine the next steps in her treatment plan.
  • Once her prednisone dose is tapered and her baseline is established, consider starting Librella for arthritis pain management.
  • Schedule follow-up acupuncture sessions and therapeutic exercises as needed to support her mobility and comfort.

• Monitoring:

  • Watch for any changes in her appetite, mobility, or behavior as her prednisone dose is tapered.
  • Notify Dr. Moretsky if she continues to drink and urinate excessively or if there are any concerns about her response to the current treatment plan.

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

— Dr Mohammad Ali