ROLLEN – A1081894
Safe - 7-20-2016 Brooklyn
ROLLEN – A1081894
**MUST LEAVE BY 6PM TODAY**
MALE, BR BRINDLE / WHITE, CHIHUAHUA SH MIX, 6 yrs
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition INJ SEVERE Intake Date 07/19/2016, From NY 11221, DueOut Date 07/22/2016,
Medical Behavior Evaluation BLUE
Medical Summary scan negative male intact S-found as stray, unable to ambulate O-QAR, pink mm, hydrated EENT-CAU, COU, no nasal d/c PPLN-all wnl H/L-no m/a, fsp, clear and increased respiratory effort on initial GI-adult dentition with large amounts of dental tartar, SNP, NMP GU-MI, nsf MSI-BCS 3.5/5, not seen on ambulation but moving RFL and RHL, no obvious fractures or pain on long bone palpation or ROM Neuro-normal cranial nerves, not seen on walk, motor present in RFL and RHL, CP deficits of LFL and LHL, withdrawal present, +/- motor in left side, painful on cervical palpation A-tetraparesis with cervical pain R/O IVDD vs other P-Rabies RHL SQ DA2PP RFL SQ CIV LHL SQ Bordetella IN pyrantel 1 ml PO activyl 0.5 ml applied Dex SP 2 mg/ml-0.45 ml IM, continue BID x 3 days (switch to oral if starts to eat. taper course) Hydromorphone 2 mg/ml-0.22 ml SQ. continue BID x 3 days then switch to tramadol if starts to eat monitor neuro status and continue dex SP and pain medication
RE EXAM: MEDICAL: Alert and aware, trembling.; Anisocoria- left pupil constricted, PLR in both, no consensual PLR in R (when light shined into L); Nonambulatory. ; CPs absent x 4, withdrawal present x 4, pain present x 4; Right legs have motor, left legs no motor; Left legs are both held out straight and stiff.; Pain on cervical palpation; Grade II-III/VI heart murmur
Assessment:; Neck pain, UMN signs left limbs, decreased reflexes right leg- r/o IVDD vs. FCE vs. other trauma vs. neoplasia; Anisocoria- r/o FCE vs. neoplasia vs. other trauma vs. IVDD vs. other; Heart murmur- r/o CVD vs. other
Rollen is a stray Chihuahua mix, brown brindle that appears to be 3 years old. He was found injured unable to move. Finder rushed and brought Rollen to ACC. Rollen during intake allow all handling but appeared severely injured.
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