CATSY – A1109970
Gone - 4-26-2017 Manhattan
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GONE 4/26/17 Catsy was brought in by police – has hind limb ataxia and may have some spinal trauma – needs further evaluation to determine what is wrong – no fractures noted – possibly spinal cord injury. Needs rescue!
CATSY – A1109970
MALE, WHITE / BLACK, DOMESTIC SH MIX,3 yrs
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition INJ SEVERE Intake Date 04/25/2017, From NY 11216, DueOut Date 04/28/2017,
Medical Behavior Evaluation YELLOW
Medical Summary DVM Intake Exam Estimated age: 3-5 years based on secondary sex characteristics and overall size Microchip noted on Intake? No – placed during LVT exam History : Brought in by police Subjective: Alert, initially allows handling but yowls and hisses when abdomen or hind legs are palpated, difficult to examine Objective BCS 5/9, MMs pink EENT: Eyes clear, ears clean, no nasal discharge noted Oral Exam: Mild tartar PLN: No enlargements noted H/L: Obstructed upper resp sounds. Does not have increased resp effort. NSR, NMA Lungs clear, eupnic ABD: Distended, painful on palp. Urinates spontaneously on abd palpation. U/G: Male intact, testicles s/s MSI: Hind legs have some motor activity but pt collapses on them and cannot walk. Dirty fur coat. Small pressure sores (alopecia, thickened skin – no ulceration) on both stifles. CNS: Mentation appropriate. Ataxic in hind limbs. Normal patellar reflexes. Bladder large and easily expressed. Sedated with buprenorphine 0.3 mg/ml 0.25 ml IM and Dexdomitor 0.07 ml IM for rads Thorax – diffuse bronchial pattern, small amount of air in esophagus. No sign pneumothorax or pneumonia. Abd: decreased serosal detail. Large bladder. Food in intestines and colon. Difficult to interpret. No hind limb, pelvic or spinal fractures noted. Reversed with 0.07 ml Antisedan Urinalysis – extremely concentrated urine, possible WBC, ketones and protein in urine but pads did not read properly (possibly due to high USG). Fully expressed bladder. Blood glucose – 147 Assessment: LMN bladder, hind limb ataxia – possible spinal trauma in L4-S3 region. No fractures seen on rads but nerve damage is still possible without a fracture. Plan: 1. Simbadol 0.5 ml SQ SID starting this evening (buprenorphine given around 12:15pm for sedation) 2. Recommend MRI for better evaluation of spinal cord – may need surgical decombression vs. cage rest and physical therapy 3. Monitor for urination – express bladder every 6 hours if not urinating on own Prognosis: Poor to guarded SURGERY: Temporary waiver due to possible spinal cord injury 1088
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