ELIZA THORNBERRY – 16647
Safe - 12-26-2017 Manhattan
ELIZA THORNBERRY – 16647
Location: Manhattan, Intake Date: 12/21/17, Intake Type: Stray
Medical Behavior: Green, Sex: Female, Age: 3 years, Weight: 13.5 lbs, Original Location: 10460
DVM Intake Exam; Estimated age: 2-5 years old based on dentition and overall appearance; Microchip noted on Intake? Scanned negative – MC placed; History : Found outside two days ago. Pt eats, plays, urinates and defecates normally but cannot walk straight.; Subjective: Energetic, friendly, allows all handling. Severely ataxic!! Observed Behavior – Whines, groans and howls – very talkative. Objective ; BAR-H, MMs pink and moist, BCS 5/9; EENT: Eyes clear, ears clean, no nasal or ocular discharge noted. Small amount of blood on muzzle – no lesions noted. Oral Exam: Mild tartar on all teeth; PLN: Mild generalized lymphadenopathy; H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic; ABD: Non painful, no masses palpated; U/G: Female, developed vulva and nipples, no spay scar seen or palpated; MSI: Ambulatory x 4, skin free of parasites, no masses noted. Mod erythema/hypotrichosis on face and feet. CNS: Mentation appropriate. Severe ataxia! Pt falls over when she shakes or turns a corner. Pt squats to urinate and defecate, but she rocks forward and back and jumps up on her hind feet while she’s trying to get into a squat. Normal CPs and UPs (hopping, paw flipping).; Rectal: Normal externally; Assessment: 1. Severe ataxia – cerebellar disease. R/O recent infection vs. chronic change due to resolved infection vs. trauma vs. cerebellar hypoplasia vs. other; 2. Lymphadenopathy – R/O related to cerebellar disease vs. allergies vs. other; 3. Erythema/thin fur on face and feet – R/O allergies; 4. Dental disease; Prognosis: Good; Plan: 1. CBC/chemistry – running now; 2. Benadryl 12.5 mg PO BID x14 days – may continue long-term if helpful; 3. Monitor ataxia; SURGERY: Okay for surgery
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