Vet AI Scribe for Rehabilitation

Bodhi

Thursday, September 17, 2026 at 3:15 PM

Rehabilitation session 5 — 6 weeks after left TPLO

Subjective

Reason for Visit

Scheduled rehabilitation session for Bodhi, a 7-year-old neutered male Labrador retriever, 6 weeks after a left tibial plateau leveling osteotomy (TPLO) for a cranial cruciate ligament rupture, performed on August 6.

Owner Report

• Using the left hind leg on every walk; still toe-touches for the first few steps after getting up from a long rest.
• Home exercises done most days: sit-to-stands and controlled leash walks of 15 minutes twice daily.
• Owner missed the weight-shifting exercises on 3 days this week.
• Carprofen stopped 2 weeks ago at the surgeon's direction; no signs of discomfort since.
• No licking at the incision; sleeping well.

Objective

Gait and Comfort

• Weight: 34.6 kg (35.2 kg at surgery)
• Lameness: Left hind 1/5 at the walk (2/5 at session 3); 2/5 at the trot
• Sit test: Sits square on the second attempt; left stifle kicked out on the first
• Pain score: Colorado State University canine acute pain scale 1/4 before the session, 1/4 after
• Incision: Healed; no thickening or heat over the plate

Measurements

• Stifle flexion (goniometry): Left 52°, right 42° (left 58° at session 3)
• Stifle extension: Left 152°, right 162° (left 146° at session 3)
• Thigh circumference, 70% of femoral length: Left 41.0 cm, right 44.5 cm (left 40.0 cm at session 3)

Treatments Today

• Underwater treadmill: 12 minutes at 1.4 km/h, water at the level of the greater trochanter; even stride throughout, mild fatigue in the last 2 minutes
• Passive range of motion: Left stifle and hip, 2 sets of 15 repetitions
• Therapeutic exercises: Sit-to-stand 3 sets of 8; cavaletti poles at hock height, 6 passes; three-leg stands (right hind lifted) 5 × 10 seconds
• Photobiomodulation (laser): Left stifle, 6 J/cm², 8 points
• Tolerated all treatments well

Assessment

• Steady progress 6 weeks after left TPLO: improved stifle extension and flexion, thigh circumference up 1 cm since session 3, lameness reduced to 1/5 at the walk.
• Persistent left thigh muscle deficit of 3.5 cm compared with the right.
• Comfortable at rest and during exercise; no signs of implant complications on palpation.

Plan

Rehabilitation

• Continue weekly sessions; increase underwater treadmill to 15 minutes if fatigue does not recur.
• Add incline walking next session if the surgeon's 8-week radiographs show progressive bone healing.
• Remeasure goniometry and thigh circumference at session 7.

Home Exercise Program

• Leash walks: increase to 20 minutes twice daily, on flat ground.
• Sit-to-stand: 3 sets of 8, once daily.
• Weight shifting while standing: 2 minutes, twice daily.
• No off-leash activity, stairs or jumping until cleared by the surgeon.

Follow-Up

• 8-week post-operative radiographs with Dr. Okafor on October 1.
• Next rehabilitation session September 24.

Client Communication:
Showed Mrs. Alvarez the measurement comparison from session 3 and explained that the thigh muscle is coming back but is still smaller on the operated side. Demonstrated the weight-shifting exercise again and agreed on a reminder for the evening routine. Reviewed the activity limits until the 8-week recheck.

— Dr. Priya Raman, DVM, CCRP