PJ – A1112917
Gone - 5-24-2017 Manhattan
GONE 5/24/17 PJ was brought in by someone who saw that he was not using his hind legs. He needs a full medical eval – no signs of fractures – possibly nerve trauma – cat was calm and allowed handling.
***HOLD FOR DOH-B***
PJ – A1112917
MALE, GRAY TABBY / WHITE, DOMESTIC SH MIX,9 mos
STRAY – ONHOLDHERE, HOLD FOR DOH-B Reason PET HEALTH
Intake condition EXAM REQ Intake Date 05/23/2017, From NY 10460, DueOut Date 06/02/2017,
Medical Behavior Evaluation No Initial Behavior
Medical Summary DVM Intake Exam Estimated age: Reported 9 months – exam is consistent with 9-15 months Microchip noted on Intake? Scanned neg History : Client reports that pt is not using hind legs. He saw a vet who said that pt had an obstruction. Subjective: Calm, alert, allows all handling Objective BCS 5/9, MMs pink and moist EENT: Eyes clear, ears clean, no nasal discharge noted. Whiskers are clipped off close to the face. Oral Exam: Clean teeth, mild gingivitis PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: Male intact, testicles S/S. Bladder very large and easy to express. MSI: Flaccid paralysis RLH – no patellar reflex, no response to hard toe pinch. Flaccid paresis LHL – weak/normal patellar reflex, weak response to hard toe pinch. Large amount of flear. No masses noted, healthy hair coat CNS: mentation appropriate – no signs of neurologic abnormalities Abd and pelvic rads: Large bladder, colon full of fecal matter. No sign of fractures or swelling. Assessment: Lower motor neuron bladder and evidence of nerve trauma in L4-S3 region – rads do not show pelvic fracture or other reason for this. R/O trauma vs. IVDD vs. other Plan 1. Simbadol 2. Onsior 3. Express bladder q6-8 hours 4. Monitor appetite 5. Recommend spinal MRI Prognosis: Fair to guarded. If pt develops increased muscle tone in next few days, he may have a good prognosis. SURGERY: Temporary waiver due to nerve damage. 1088
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