LADY GODIVA – 29616

Manhattan Center

Lady Godiva, 29616,  Black DSH, 6 Years Old,  Female, 7 lbs, Stray 5/29/18

Medical:

Medications
Medication
Amount Dispensed
Frequency
Date From
Date To
Doses Administered
Vet Name
Reason
Notes
Clindamycin Supsension 25 mg/mL
0 ml
1.5 ml, 2 times every 1 day(s)
30-May-2018
After completed 14 times
0

Vitamin B Complex INJ
0 ml
0.5 ml every 1 day(s)
30-May-2018
After completed 5 times
0

Give I/M
Metronidazole 50 mg/ML
0 ml
1 ml, 2 times every 1 day(s)
31-May-2018
After completed 10 times
0

Fortiflora (probiotic supplement)
0
1 every 1 day(s)
31-May-2018
After completed 5 times
0

Drug Usage
No drugs administered to this animal.

Vet Consultations
Date
Reasons
Vet Notes
Vet
Date Resolved
31-May-2018
Progress Exam
Vet Notes: 3:13 PM

S/O – eating and drinking. BARH. Pale brown liquid diarrhea

MSK – Ataxia and hind limb paresis still present. Sitting splay legged in kennel.

Abdomen – firm, distended/round, gas filled, mild discomfort.

EENT – clear, no ocular or no nasal discharge.

Radiographic evaluation
Lateral and V/D xrays
– Large Food filled Stomach/distended with some boney fragments

A
– BARH
– Ataxia, hind limb paresis (splay legged)
– Firm round/distended abdomen with mild
discomfort on palpation
– Diarrhea: R/O Dietary indiscretion vs infectious vs obstruction
– Distended food filled abdomen on x-rays

P
– Sedated abdominal xrays – lateral and V/D
– Continue on current treatment plan
– Fortiflora SID for 5 days
– Feed I/D Food only
– Monitor abdominal distension and diaarhea
VET 991493

31-May-2018
Tech Exam
L V T Notes: 12:04 PM

Sedated for radiographs with 0.1ml Butorphanol (10mg/ml, bottle #9), and 0.1ml Dexdomitor IV. Two view radiogaphs obtained. Patient had extreme diarrhea during sedation. Sedation did not completely sedate patient. Gave a warm bath to clean the feces off of the pet. Returned to kennel and resumed IVF.
LVT-E 991215
31-May-2018
30-May-2018
DVM Intake
Vet Notes: 11:01 AM

[DVM Intake]
DVM Intake Exam

Estimated age: 10
Microchip noted on Intake? n
Microchip Number (If Applicable):

History : stray transferred from VERG Brooklyn – refer to PE NOTES –

Subjective: QARH – eating and drinking

Observed Behavior – patient lethargic/dull, 3% dehydrated

Evidence of Cruelty seen –
n
Evidence of Trauma seen –
n

Objective

T = 101
P = 240 – Gallop rhythm
R = wnl
BCS = 5/9

EENT: Eyes clear, ears clean, no nasal or ocular discharge noted
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Firm, tense, bloated – mild discomfort when palpated
U/G: Intact
MSI: Motor deficits on the hind-end, flea dirt, seborrhea
CNS: Ataxia with marked hind end motor deficits when trying to walk hunches and is splayed legged when trying and then falls to side.

Placement reflex normal on all fours
Wheelbarrow normal

Rectal: externally normal

Assessment:

1) Hind End motor deficits
2) Ataxia
3) Sebbrohea/flea dirt
4) Lethargy

VERG Clinic- ALREADY completed
– Capstar application
– Vit B Complex/Thiamine 50mg IM @ 7pm
– Azithromycin @ 5pm

Blood work
– Mild Neutrophilia (15)
– Mild Hyperglycemia

Radiographs
– Cardiomegaly and large bony fragments in stomach

Assessment –
– Cerebellar lesion (r/o congenital vs infectious vs trauma vs neoplasia)
– R/O Infectious causes with IDEXX toxo, corona, FELV/ FIV titres

Prognosis: poor to fair

Plan:

1) Place on fluids at 8ml/hr
2) CBC/CHEM
3) Place on Thaimine IM 50 mg SID for 5 days and continue on Thaimine orally after
4) Clindamycin 37.5 mg PO BID
5) Idexx Serology- Toxoplasma, coronavirus, FELV/FIV
6) Complete intake tx’s
7) Repeat Abdominal xrays June 1st 2017 V/D and Lateral

SURGERY:

Permanent waiver due to age
VET 991493

30-May-2018
Tech Exam
L V T Notes: 9:46 AM

Ear cytology: no mites seen. staphylococci 1+ yeast 1+
LVT-E 991215
30-May-2018
30-May-2018
Tech Exam
L V T Notes: 8:03 AM

Blood sample obtained from LHL medial saphenous vein for IH blood work

Behavior Assesment Pending

 

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