BEAR – 34400

BEAR – 34400

Location: Brooklyn; Intake Date: 7/14/18; Intake Type: Stray; Medical

Behavior: Green; Sex: Male; Age: 9 years; Weight: 56 lbs; Original Location:

11316

Vet Notes: 12:12 PM – DVM Intake Exam: Estimated age: Approximately 9-12 years Microchip noted on Intake? Negative scan History : Stray Subjective: QAR, gentle, allows all handling, eats voraciously when offered canned food. Evidence of Cruelty seen – neglect  Evidence of Trauma seen – none  Objective:  P = wnl R = wnl BCS = 2/9 EENT: Eyes – marked ptosis OU with periocular erythema/swelling, mucoid discharge with cloudy corneas OU, nuc sclerosis OU. Ears heavy thick grey/brown discharge/debris AU, pinnae edges rough/crusted AU. No nasal discharge noted Oral Exam: Moderate to severe tartar, gingivitis, gingival recession PLN: No enlargements noted H/L: NSR, grade III/VI heart murmur, SSP, Lungs clear, eupnic ABD: Tense, but non painful, no masses palpated U/G: Intact male with two scrotal testicles, one smaller than the other MSI: Ambulatory x 4, but severe pelvic limb ataxia and weakness, significantly delayed CPs, withdrawal and deep pain present, no spinal pain, bilaterally thickened stifles, unable to fully extend hips, crepitus in hips bilaterally, severe generalized muscle atrophy and emaciation, decreased skin turgor, several dermal nodules (sebaceous  adenoma/skin tag), diffuse/generalized epidermal crusting with easily epilated fur and yeasty smell,  CNS: Mentation appropriate Rectal: Externally normal. Assessment: Pelvic limb ataxia/weakness – ro OA +/- emaciation/muscle atrophy vs Degenerative myelopathy vs IVDD vs neoplasia vs other neurologic dz Emaciation/muscle atrophy – ro neglect vs neoplasia vs other Dehydration. Heart murmur. Marked ptosis/conjunctivitis Epidermal crusts/easily epilated fur  Prognosis: Guarded pending diagnostics and response to care/treatment Plan:  CBC/Chem/T4SQF LRS 600ml Ears/eyes cleaned. Ears appear healthy once debris/dirt cleaned. Eye fluorescein stain – very faint generalized corneal uptake (no obvious focal ulceration) Intake treatments
Continue to monitor while at BACC (appetite, mobility) In future, recommend cardio workup, dental cleaning. Pending response to adequate diet and care, likely will need longterm management/rehabilitation for pelvic limb weakness and OA  SURGERY:  Permanent waiver due to heart murmur

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