Post-Op Pain and the Controlled-Substance Log Discrepancy
A 6-year-old male neutered Labrador (28 kg) had a TPLO 18 hours ago. Discharge orders: carprofen 4.4 mg/kg PO q24h and tramadol 4 mg/kg PO q8-12h PRN. The owner calls at 2100 saying the dog is panting, restless, and will not settle; she gave the last tramadol at 1700 and has been dosing every 8 hours. Temperature 102.1 F, HR 118, respiratory rate 44, mucous membranes pink, capillary refill under 2 seconds. She also mentions she has been taking the dog's tramadol herself for a back injury and asks whether she can give an extra dose now. The clinic's tramadol bottle count is 14 tablets lower than the running log indicates. The veterinarian is unreachable until morning; the practice has a written protocol allowing technicians to triage by phone and escalate to the on-call relief veterinarian.
1. Sort the clinical findings into what is expected post-op versus what warrants escalation, and state the disposition you would recommend by phone.
Read the worked answer
Expected after major orthopedic surgery at 18 h: mild tachypnea and restlessness from pain, anxiety, or residual anesthetic effects; HR 118 in a painful 28 kg dog is plausible; temperature 102.1 F and CRT under 2 s are reassuring and argue against shock or sepsis.
Concerning: panting plus restlessness that is worsening despite q8h tramadol suggests inadequate analgesia, not just anxiety. Respiratory rate 44 with pink membranes is more consistent with pain/heat/anxiety than hypoxia, but it should be rechecked after any intervention.
Action: Do not authorize an extra dose over the phone. The dog is already at the top of the q8h interval, and adding an opioid without veterinary oversight is outside technician scope. Call the on-call relief veterinarian now - the protocol permits escalation, and 'vet unreachable until morning' does not apply because a relief vet exists. While awaiting callback, advise the owner to keep the dog confined, offer water, and apply a cool compress if the dog is panting from warmth; instruct her to go to the emergency clinic if breathing becomes labored, gums pale, or the dog becomes nonresponsive.
Key judgment: normal vital signs do not rule out a pain-control failure, and the presence of a relief vet removes the justification for waiting.
2. How should the controlled-substance discrepancy and the owner's self-medication be handled?
Read the worked answer
Treat these as two separate events.
1. The count discrepancy (14 tablets). Do not adjust the log to make it balance. Perform a witnessed recount, document the shortage on the controlled-substance record with date, time, and initials of both counters, and notify the veterinarian and the DEA registrant (the practice owner) per the clinic's written controlled-substance policy. In Alabama, controlled substances are tracked under state and federal rules; unexplained losses require documentation and may require reporting. Preserve the bottle and the log; do not discard anything.
2. Owner self-medication. The owner has admitted diverting a Schedule IV drug prescribed for her dog. This is a client-safety and legal issue, not a dispensing question. Do not advise her on human dosing, do not refill early, and do not dispense more tramadol to that household without veterinarian direction. Document her statement verbatim in the medical record and flag the account so the next prescriber sees it.
3. Do not conflate them. The shortage may be a counting error, a double-dispense, or diversion; the owner's admission is separate. Report both to the veterinarian, but avoid accusing the owner of causing the shortage without evidence - state facts in the record, not conclusions.