SALEM – A1123741
Safe - 9-10-2017 Manhattan Rescue: K9KASTLE Please honor your pledges: https://www.classy.org/checkout/donation?eid=127094
SAFE 9/10/17 Handsome Salem was brought in as a stray. He is a bit dehydrated, and very ataxic. Needs further medical eval/bloodwork to determine what is wrong. Already neutered and needs a home.
MANHATTAN CENTER
SALEM – A1123741
NEUTERED MALE, BLACK / WHITE, DOMESTIC SH MIX,8 yrs
STRAY – ONHOLDAVAI, HOLD FOR ID Reason STRAY
Intake condition EXAM REQ Intake Date 08/30/2017, From NY 10457, DueOut Date 09/02/2017,
Medical Behavior Evaluation BLUE
Medical Summary DVM Intake Exam Estimated age: 8 years Microchip noted on Intake? no History : surrender Subjective: QAR, 10% dehydrated Observed Behavior – disoriented, but quiet, allows exam/treatment Evidence of Cruelty seen – no Evidence of Trauma seen – possible head trauma Objective P = 160 R = 20 BCS: 3/9 EENT: aniscoria (L>R) , ears clean, no nasal discharge noted Oral Exam: negative oral PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated, doughy (dehydrated), kidneys seem enlarged U/G: male castrated MSI: ambulatory x 4, but very ataxic, no obvious fractures or luxations, skin free of parasites, no masses noted, dirty, matted haircoat CNS: no cp deficits, or obvious cranial nerve deficits, but very ataxic Assessment: neurologic signs, aniscoria: rule out cerebellar hypoplasia vs other CNS disease vs metabolic vs trauma vs neoplasia vs infect/inflamm. Plan: continue to monitor at MACC given 100 ml 0.9 NACL SQ recommend cbc/chem to rule out metablic/infectious causes consider iv catheter, iv fluids/supportive care, pend bloodwork results. Prognosis: guarded SURGERY:already altered
Weight 6.6
Medical:
Re-exam 9/2/17:
BARH mm pink
H/L wnl
dermal mass on top of head
moderate tetraataxia (able to stand, frequent falling), CN exam wnl,
A: URI, Likely CH r/o other intracranial causes such as tumor
P: likey pt has had this condition is congenital considering h/o kept in cage. continue with URI tx
9/1/17
Hx: Reportedly kep in a cage, likely because pt is ataxic. Intake 8/30: Dehydrated and ataxic, given convenia and placed on IVF. Bloodwork done 8/30/17: Moderate, regenerative anemia (25%), reticulocytes (144 K/uL), mild monocytosis (0.73), mild to moderate basophilia. Chemistry was WNL. On 8/31, pt had mild serous nasal discharge and was sneezing, so pt was moved to med iso and started on doxycycline.
S: Alert, comes over to say hi, allows all handling, very relaxed
O: BAR, MMs pink
EENT: Mild mucoid ocular discharge, no nasal discharge today. Moderate black granular debris AU. Small firm alopecic nodule on dorsal skull.
H/L: Purring on auscultation, eupnic
Abd: Soft, nonpainful, not distended
M/S/I: Many small and medium-sized mats across body
Neuro: Very ataxic – has difficulty taking even a single step without falling over. Leans on my leg for support. Appears alert and appropriate.
A
1. URI – resolving
2. Ataxia – R/O cerebellar hypoplasia vs Toxoplasma vs. other infection
3. Anemia – Anemia of chronic disease vs. infectious vs other
4. Nodule on skull – R/O sebaceous adenoma vs. other tumor
5. Likely ear mites
P:
1. Continue doxycycline
2. Groom
3. Recheck CBC in 10-14 days
4. Clean ears, give Tresaderm AU BID x10 days
Re-exam 9/1/17:
Hx: Reportedly kep in a cage, likely because pt is ataxic. Intake 8/30: Dehydrated and ataxic, given convenia and placed on IVF. Bloodwork done 8/30/17: Moderate, regenerative anemia (25%), reticulocytes (144 K/uL), mild monocytosis (0.73), mild to moderate basophilia. Chemistry was WNL. On 8/31, pt had mild serous nasal discharge and was sneezing, so pt was moved to med iso and started on doxycycline.
S: Alert, comes over to say hi, allows all handling, very relaxed
O: BAR, MMs pink
EENT: Mild mucoid ocular discharge, no nasal discharge today. Moderate black granular debris AU. Small firm alopecic nodule on dorsal skull.
H/L: Purring on auscultation, eupnic
Abd: Soft, nonpainful, not distended
M/S/I: Many small and medium-sized mats across body
Neuro: Very ataxic – has difficulty taking even a single step without falling over. Leans on my leg for support. Appears alert and appropriate.
A
1. URI – resolving
2. Ataxia – R/O cerebellar hypoplasia vs Toxoplasma vs. other infection
3. Anemia – Anemia of chronic disease vs. infectious vs other
4. Nodule on skull – R/O sebaceous adenoma vs. other tumor
5. Likely ear mites
P:
1. Continue doxycycline
2. Groom
3. Recheck CBC in 10-14 days
4. Clean ears, give Tresaderm AU BID x10 days
Re-exam 8/31/17:
Hx: dehydrated, ataxic on intake; given convenia and placed on IVF which were running at 5 ml/hr; blood work available for review
CBC-moderate, regenerative anemia (25%), reticulocytes (144 K/uL), mild monocytosis (0.73), mild to moderate basophilia
Chemistry-WNL
S/O
good appetite
BAR, very affectionate and interactive
mm pk, moist
mild serous nasal discharge, sneezing intermittently
OU-mild to moderate blepharospasm
purring on auscultation
soft, nonpainful, sl doughy abdomen
unthrifty hair coat
ambulatory ataxia, intention tremors when eating
A
URI
Ataxia-r/o cerebellar hypoplasia vs infection (toxoplasma, mycoplasma)
Anemia-r/o infectious vs other
Thrombocytopenia-r/o lab error vs consumption vs other
P
d/c IVF
doxycycline 50 mg/ml: 0.6 ml PO SID x 10 days
rec’d recheck CBC in 10-14 days
prognosis: fair, suspect cerebellar hypoplasia but cannot rule out other causes of ataxia, especially with moderate anemia; consider neuro consult after placement vs empirical treatment with clindamycin and/or doxycycline
Ataxia-r/o cerebe
DVM Exam 8/30/17:
Estimated age: 8 years
Microchip noted on Intake? no
History : surrender
Subjective: QAR, 10% dehydrated
Observed Behavior – disoriented, but quiet, allows exam/treatment
Evidence of Cruelty seen – no
Evidence of Trauma seen – possible head trauma
Objective
P = 160 R = 20 BCS: 3/9
EENT: aniscoria (L>R) , ears clean, no nasal discharge noted
Oral Exam: negative oral
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated, doughy (dehydrated), kidneys seem enlarged
U/G: male castrated
MSI: ambulatory x 4, but very ataxic, no obvious fractures or luxations, skin free of parasites, no masses noted, dirty, matted haircoat
CNS: no cp deficits, or obvious cranial nerve deficits, but very ataxic
Assessment: neurologic signs, aniscoria: rule out cerebellar hypoplasia vs other CNS disease vs metabolic vs trauma vs neoplasia vs infect/inflamm.
Plan: continue to monitor at MACC
given 100 ml 0.9 NACL SQ
recommend cbc/chem to rule out metablic/infectious causes
consider iv catheter, iv fluids/supportive care, pend bloodwork results.
Prognosis: guarded
SURGERY:already altered
Enrichment Notes:
Severe ataxia, aniscoria, possibly enlarged kidneys, matted. Resting on bedding, soft eyes and body. Tried to come to the front when door opened. Leaned and arched into pets, purred, ate offered treats. Super sweet, very wobbly.
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