CANDY – 21083

CANDY – 21083

**NEEDS IMMEDIATE FOLLOW UP VET CARE FOR HEAD TRAUMA**

12 yr. female white small dog, stray, 10 pounds:

DVM Intake Exam; Estimated age:10-12 years; Microchip noted on Intake?  History :police received a call about a dog that fell out of a window, police brought dog to ACC; dog has pink collar and Rabies tag; Subjective:obtunded, minimally responsive to stimuli, intermittent yipping; Observed Behavior -laterally recumbent, obtunded; Evidence of Trauma seen -obtunded, lateral recumbent, suspect head trauma; Objective ; BCS 4/9; EENT:  -OS:; nystagmus noted initially; ventral strabismus, mature cataract, mild conjunctivitis, episcleral injection; menace negative, palpebral positive -OD: nystagmus noted initially then resolved, ventral strabismus, mild conjunctivitis, episcleral injection; Oral Exam: mm pale pk, tacky; CRT prolonged; severe dental disease with gingival recession, especially around canines; PLN: No enlargements noted; H/L: HR initially 80 bpm, increased to 100 bpm after fluid bolus; mild tachypnea (45 breaths/min), clear lung sounds; no murmurs/arrhythmias; ABD: soft, nonpainful, sl doughy; U/G: female; MSI/CNS:  -obtunded mentation, laterally recumbent; -absent proprioception and withdrawal; -initially does not respond to noxious stimuli but began moving hind limbs slightly and superficial pain noted to be intact; -overgrown hair coat, circumferential matting around distal limbs; -ingrown nails on hindlimbs with irritation of nail bed; -abscess under main paw pad on RH with bleeding, suspect due to matted/ingrown toenail -no obvious fractures or orthopedic injuries; Rectal:grossly normal, tone present; Assessment; 1. Obtunded-suspect head trauma; 2. Severe paresis-r/o head trauma vs spinal trauma (IVDD vs other); 3. Geriatric underlying 4. Cataracts; 5. In grown toe nails; Prognosis:poor to guarded; Plan: -gave 0.1 mg/kg hydromorphone IM; -placed IVC, gave 100 ml bolus over 30 minutes, then gave additional 50 ml bolus over 30 min, then continue at 15 ml/hr; -gave 0.25 ml dexamethasone SP IV; -gave 30 ml mannitol slowly IV after initial bolus; -ofloxacin OU BID-TID; -convenia injection 0.45 ml SQ; -monitor neuro status, consider EHR if no significant improvement; SURGERY:permanent waiver due to geriatric

My medical notes are…

Per Vet, Tues. Feb. 20 update: Candy is doing fantastic today!! She is strongly ambulatory today with a good appetite. She even had a normal bowel movement! She does have some mild hematuria which is suspected to be traumatic and should resolve. Her blood work just showed one liver value that is pretty elevated but I suspect this is likely due to her trauma and should be recheck in about 5-7 days. The biggest long term issue I see is that she does have chronic changes to her eyes which I think is likely glaucoma It’s preferable for her to go to a hospital after leaving

Vet Notes: 11:33 AM CBC-mild, non regenerative anemia (34.7%), mild neutrophilia (13.34), mild lymphopenia; Chemistry-moderate to severely elevated ALT, all other values WNL; A 1. Mild anemia-r/o mild blood loss secondary to trauma (bladder, intracranial) 2. Elevated ALT-suspect secondary to trauma, r/o primary liver disease vs other P -recommend rechecking ALT in 7-10 days to ensure it is improving

Vet Notes: 10:04 AM Reportedly fell from a building yesterday, presented obtunded, was treated with IVF, dexamethasone, and a dose of mannitol; showed significant improvement through the day, IVF running at 15 ml/hr S/O -QAR, docile and allows all handling -good appetite -normal bowel movement this morning, no apparent discomfort when posturing -several episodes of hematuria in cage -mm pk, sl tacky; CRT <2 sec -no nasal discharge or sneezing -OS: mild to moderate buphthalmia, mild corneal edema, mild hyphema, immature cataract; small superficial corneal defect mid/ventral field; episcleral injection; -OD: mild buphthalmia, mild corneal edema, mild to moderate episcleral injection -non visual OU -eupnic, clear lung sounds; no murmurs/arrhythmias, SSFP -ambulatory x 4!!! mildly delayed CP on hindlimbs -digital pad on digit I on RH thickened and erythematous, had abscess that was expressed yesterday; do not suspect this is a mass but rather hypertrophy of digital pad -mild abrasion along dorsum and medial aspect of hind limbs A 1. Head trauma, significantly improved 2. Buphthalmia OU-r/o glaucoma vs other 3. Dental disease 4. Digital pad abscess, RH-r/o infection vs mass 5. Hematuria-suspect traumatic, r/o UTI; no stones visible on radiographs P -replaced IVC this morning in LF -continue IVF at 10 ml/hr through the day -continue gabapentin and ofloxacin -recommend tonometry (do not have working tonopen) -prognosis: fair to good, has shown significant improvement within 24 hours; chronic ocular disease will likely require management

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