BOLLO – A1096997
Gone - 11-17-2016 Brooklyn
BOLLO – A1096997
**MUST LEAVE BY 6PM 11/17/16**
MALE, GRAY / WHITE, AMERICAN STAFF MIX, 8 yrs
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition ILLNESS Intake Date 11/16/2016, From NY 11233, DueOut Date 11/19/2016,
Medical Behavior Evaluation GREEN
Medical Summary 11/16/16 Check dog with neurologic problem. Microchip scan neg. O: QARH. mm=pink, moist, CRT<2 s. Friendly, wagging tail. Very easy to handle/examine. ORAL: Mod calculus, worn teeth. EENT: AS – stenotic canal, erythema and canal swelling, mod. purulent discharge. OD – scleral injection, mucopurulent discharge. H/L: Lungs clear, no coughing or dyspnea. Gr. 1/6 systolic cardiac murmur ausculted on left side. ABD/UG: Intact male. Palpation WNL. MS: Slowly, weakly ambulatory x 4. Can stand for a short period of time, then will slowly start sinking down and fall to the right. Able to rise with assistance. Left tarsus – crepitus, decreased range of motion, thickening. NEURO: Ataxic gait, slight head wobbling. No head tilt or nystagmus. INTEG: Abrasion lower right lip at commissure. A: Neurologic disease – DDX: Toxin ingestion (cannabis, other), peripheral or central CNS disease(inflammatory, infectious, neoplastic), metabolic disease. Chronic Otitis externa AS. Conjunctivitis OD. Small lip abrasion may be due to falling. P: CBC/Blood chemistry: CBC: Mild lymphopenia, otherwise WNL. HCT=41.3%. CHEM: WNL. Cleaned AS with ear cleanser, applied Otibiotic. Continue BID x 10 days. Cleaned OD, applied TAB ointment. Continue BID x 10 days. Cleaned abrasion on lip with chlorhexidene. No specific treatment indicated beyond monitoring signs. If start to resolve, then supportive of a toxin ingestion. Fair to good prognosis. 5 pm: Offered small amount of canned food – good appetite. Able to eat from dish in spite of head tremors.
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