BALDWIN – A1102018
Safe -
1-24-2017 Brooklyn
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SAFE 01/24/17
BALDWIN – A1102018
NEUTERED MALE, WHITE, POODLE TOY MIX, 10 yrs
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition EXAM REQ Intake Date 01/23/2017, From NY 11207, DueOut Date 01/26/2017,
Medical Behavior Evaluation GREEN
Medical Summary S/O: Patient presented to medical with hindlimb paralysis. BAR on presentation, sitting upright on forelimbs. mm = p/m; CRT = < 2 sec EENT = severe periodontal disease (grade III/VI); mild dark brown waxy debris, AS, but clean otherwise, NND, clear OU H/L = difficult to auscult due to trembling; 138 bpm, PSS, NSR, NMA ABD = slightly tense, non-painful, no obvious masses palpable, no pain elicited GU = MN MS = BCS: 3-4/9, Non-ambulatory in hind limbs, able to be placed in standing position on all 4 limbs for short time LN = wnl CNS = No obvious cranial nerve deficits, no neck/spinal pain elicited. Propioceptive deficits detected – crossing over hind limbs, absent paw placement bilaterally. Patellar reflex present bilaterally. Deep pain present bilaterally. Anal tone present A: Geriatric MN Poodle with: Hindlimb paresis – r/o IVDD vs. trauma vs. other neurological dental disease P: Recommend further neurological assessment with diagnostics/treatment (blood work, anti-inflammatory drugs, +/- advanced imaging) and strict cage rest for at least 6 weeks. Tramadol – 25 mg PO BID x 7 days Re-assess pain daily PX: guarded
Weight 12.5
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