ARCHIE – 14581

Brooklyn Center

Archie 14581, 5-6 Months Old, Black and White DSH, Neutered, 5 lbs 9.92 oz, Stray 11/25/17

Medical:

11/26/17:

DVM Exam
Subjective: patient is QAR, appears to have ate some food and water over night. Evidence of urine on patient. Patient is unable to ambulate hind limb, paraplegic, no rectal tone. Expressed bladder, good stream, hematuria.
Objective
P-196
R-30
ABD: Non painful, no masses palpated
U/G: hematuria
CNS: paraplegic, no rectal tone, no sensation to hind limbs and tail.
Assessment – Fractured L-4, R/O Neurologic bladder
Prognosis: Guarded
Plan: Convenia 0.3ml SQ, continue Simbadol SID.
Request for total body radiograph and contact new hope for placement

11/25/17:

Lateral and VD: The lumbar spine shows a ventral deviation at the L3/L4 junction (roughly 25 degrees). On lateral view L4 has a linear radiolucent defect along the mid-vertebral body and an irregular region of mildly increased opacity near the cranial border. On VD view the intervertebral space at L3/L4 is deemed irregular with a cranial displacement of the right lateral vertebral body — a flexion-distraction fracture is suspected at L4.
There are no obvious fractures or dislocations of pelvis or long bones. There is a small amount of air in SQ space of caudal dorsum subcutaneous space. The abdominal organs appear wnl.

Vet Notes: 3:29 PM

DVM Intake Exam
Estimated age: ~5-6months
Microchip noted on Intake? no
History : Brought in by field, reportedly had hind limb stuck in grate
Subjective: QAR. Minimal interest in food
Observed Behavior – QARH. Calm, allows all handling
Evidence of Cruelty seen – no
Evidence of Trauma seen – yes
Objective
P = WNL R = WNL BCS
EENT: Eyes clear, ears clean, no nasal discharge noted
Oral Exam: Upper left canine fractured to gum line, pale pink mm, adult dentition erupting
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated – medium sized soft bladder, expressed large amount of bloody urine
U/G: Neutered, tattoo seen
MSI: Ambulatory x 2, dragging hind limbs, deep pain present in both hind limbs (L>R), skin free of parasites, no masses noted, healthy hair coat
CNS: mentation appropriate – no signs of neurologic abnormalities
Assessment: Traumatic injury to hind end, +/- internal injuries; injury to L4
Plan: Rec simbadol 0.33ml SQ q24 x 3 days. Continue to monitor while at BACC
Prognosis: Fair – depending on level of improvement in next few days

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