SKITTLES – 25795

DVM Intake Exam

Estimated age: Estimated 6-12 years old based on dentition and overall appearance
Microchip noted on Intake? Scanned negative on intake

History : Stray, found outside, not moving

Subjective: Alert, yowls when bothered. Reluctant to walk; ataxic in HLs.

Observed Behavior – Hisses and swats when I try to examine face or place a harness on pt to evaluate walking

Evidence of Cruelty seen – None

Evidence of Trauma seen – None

Objective
BAR, estimated 5% dehydrated based on decreased skin turgor. BCS 3/9. Muscle wasting over HLs.
EENT: Eyes clear, ears clean, no nasal or ocular discharge noted
Oral Exam: Missing left maxillary canine tooth; gingival hyperplasia and possible fracture on left maxillary PM2. Moderate gingivitis over other teeth.
PLN: No enlargements noted
H/L: NSR, NMA, Lungs clear, eupnic
ABD: Tense. Not distended, no masses palpated
U/G: Female, small linear ventral scar palpated and visualized when shaved.
MSI: Muscle wasting HLs. HLs are ataxic and pt falls to one side when walking. Skin free of parasites, no masses noted, healthy hair coat.
CNS: Mild head tilt to the left. Mentation appropriate.
Rectal: Normal externally.

Assessment
1. HL ataxia – R/O central vestibular disease (cerebellar) vs. peripheral (otitis interna, neuropathy) vs. injury to HLs (pelvic fx) vs. other cause
2. Head tilt – R/O related to cause of ataxia vs. other cause
3. Dehydration, underweight – R/O related to cause of ataxia vs. other underlying medical problem
4. Dental disease

Prognosis: Fair

Plan:
1. Sedate with Dexdomitor 0.2 ml and butorphanol 0.1 ml IM
2. CBC/chem/T4/combo test/microchip
3. Pelvic rads