Plan of Action:

1. Bloodwork:
We would like to do a Superchem, CBC, T3/T4, and a urinalysis on Bonnie.  Since Bonnie is 
six years old, she is getting into the ÔolderÓ range for large breed dogs.  We would like to 
evaluate organ function ( just to assure she is healthy as well as this could be used a preanesthetic 
workup for the orthopedic exam under general anesthesia and possibly surgery if needed ).  We 
are concerned with BonnieÕs weight. She appears to be overweight despite seemingly regular 
exercise.  Conditions that may contribute to obesity include hypothyroidism and CushingÕs ( 
distended abdomen, mimicking obesity).  With hyperadrenocorticism there can be increased 
drawer movement with multiple ligament damage most likely due to decrease in protein 
catabolism and decrease in collagen strength and well as muscle atrophy which can lead to a 
increase stress.  So we would look on initial bloodwork for possible elevation in alkaline 
phosphatase with no other abnormalities, and possible isosthenuria.  ( Further testing of this 
would need ACTH stim but would need indications for doing that).  
	A CBC may give indication of presence of inflammatory disease. Look for increases in 
neutrophils, monocytes,. Look for immunocytes for indication of antigenic stimulation of 
somesort. Inflammation may indicate sepsis but dog appears normal otherwise; may also indicate 
tick borne vector disease such as lyme/erhlichiosis eventhough these often present with other 
clinical signs but lameness can be the major presenting complaint.
	Look carefully for any other abnormalities such as hypercalcemia which may indicate 
presence of neoplasm ( she is 6 years old so we do need to think neoplasm, though probably 
unlikely)  that may be secreting a parathyroid like hormone causing increase in bone resorption 
leading to weakened joints.

Also given the possibility of tick borne disease we would also like to have a Tick titer panel.

2. Arthrocentesis
This was already performed and we are waitign for results.  We are hoping this will distinguish 
an inflammatory from a non-inflammatory reaction.  In inflammation we would expect to see a 
fluid analysis of: protein electrophorectic pattern of synovial fluid is altered, a decrease of 
sugars, increase in cell population, and a change in cell type ration.  
Guildlines for synovial fluid analysis are as follows:

				Normal	DJD		immune mediated		Septic
								Arthritis			arthritis
Color			clear/pale yellow	yellow		yellow +/- blood		            yellow+/- blood
Clarity			transparent	transparent	transp/opaque			opaque
Viscosity			very high	high		low/very low			very low
Mucin clot		good		good-fair	fair-poor			poor
Spontaneous clot		none		+/-		often				often
White cells/mm3		<1000		1000-5000	>5000				>5000
Neutrophils		<5%		<10%		10-95%			>90%
Mononuclear cells	>95%		>90%		5-90%				<10%
Protein (gm/dl)		2.0-2.5		2.0-3.0		2.5-5.0				>4.0
Glucose(% )		>90%		N/A		N/A				<50

3. We would like to perform an orthopedic exam under general sedation and obtain radiographs.  
We would like to reasses the hip joint laxity. With just sedation we may have missed a mild 
laxity in the hip joint which would be indicative of some type of degenerative change in the hip 
joint. Any degenerative change in the hip joint, even though subclinical in presentation at this 
time, may play a role in increasing the forces placed on any joint distally, epecially the stifle 
joint.   The lateral and VD radiographs of the pelvis would help to rule this out. We would also 
like to assess conformation of the hips because, again, eventhough they may not be presenting 
clinically with an abnormalitiy, there may be a slight deviation from normal, again placing 
abnormal stresses on the stifle leading to a cruciate rupture.  
We would also like to take VD/lateral views of BOTH stifles to assess the extent of the effusion. 
In early cruciate ligament disruption there is usually synovial fluid leading to loss of the 
infrapatellar fat pad dn distention of caudal joint capsule with loss of displacement of the fascial 
planes.  Osteophyte production would indicate a more chronic condition. Bonnie may well have 
stretched or partially torn her ligament before but now there may be a full tear. 

4. We would ideally like to have a weight for Bonnie to calculate what her caloric intake should 
be to make sure she is not being overfed despite regular exercise.  We are unable to give a 
definite body condition score ( which with cushing would actually be low because the obesity is 
more due to abdominal distention but the actually body/limbs exhibit muscle wasting; with 
hypothyroidism there may be an increased in BCS)