[DVM Intake] DVM Intake Exam Estimated age: 6-8 Microchip noted on Intake? yes initially but couldn’t be located when rescanned (newer number with). History : Found as stray today and picked up by ACO in Bronx. Had 2 seizure type episodes where fell over on way to truck. Subjective: BAR Hydr wnl Observed Behavior – Ok to examine initially but 2nd attempt to rescan microchip dog snapped at scanner Evidence of Cruelty seen – None obviou Evidence of Trauma seen – None obvious Objective T = NE P = 160 R = wnl BCS 5/9 EENT: Eyes clear, ears clean-no blood on otoscope exam, no nasal or ocular discharge noted Oral Exam: mild dental dz PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: Involuted mg MSI: Ambulatory x 4, skin free of parasites, no masses noted, long nails, alopecia perineal area CNS: Head tilt and circling, anisocoria, ataxic appeared to alternate but predominately to right, menace present OU, cp wnl x 4 Assessment: hx seizures per driver r/o seizures vs inability to maintain standing posture neuro deficits r/o trauma, toxin, neoplasia, parasites, inf, other CBC/Chem: mild hypernatremia, hyperchloremia r/o lab, clinical significance Prognosis: guarded to grave pending dx Plan: IVC attempt unrewarding, monitor for seizure in medical overnight CBC/Chem Rescan for microchip tomorrow-couldn’t locate when rescanned. consider repeating chem 12/13/17 to monitor electrolyte,rads am for foreign material, other dx, ehr SURGERY: Temporary waiver due to pending dx of dz process

CBC nsf Chem Na 162 (144-160) Cl 125 (109-122) other nsf No significant elevations in bun/cr/le, Mild Na, Cl r/o lab, clinical signficance

[Progress Exam Template] S: BAR, weakly ambulatory x 4 (ataxic x 4), falls more towards the left side O: Hx 2 seizures on transport – none reported here. Falling left, ataxia x , previous labs wnl EENT:wnl Oral Exam:muzzled pink H/L:160 bpm, no murmur/no arrhythmia, ssp, clr Abd: spay tattoo, but likely later in age due to prominent vulva and mg’s MSI:short, spastic, toe-tapping gait forelimbs, ataxia hind, head tilting bilterally, but will fall left, plr and menace, grade 4 mpl bilaterally, intention tremor Mentation:bar A: r/o chronic vs acute r/o congenital (cerebellar hypoplasia vs other) vs inflammatory vs infection vs trauma vs neoplasia, toxin/fb mpl’s starting trazadone as dog is very stressed and barking and whining throughout the day. P: today lat and vd abdo and thoracic rads will need nsaid/jt supplement in long term for mpl Is the Initial Medical Status being Changed? New Medical Status:n Is the Initial Behavior Status being Changed? New Behavior Color: n

Able to get lateral abdo and thorax – no evidence of metallic fb to account for neurological signs. +/- rounding of liver and decreased serosal detail spondylosis

This dog weighs 39#

Hx: had 2 seizures on transport on 12/22 PM; ataxia noted on intake; blood work overall WNL; placed on trazodone due to anxiety, no further seizure activity S/O -BAR, friendly, loose wiggly body language and allows all handling; muzzle for exam due to previous behavioral concerns -good appetite -mm pk, sl tacky -no nasal discharge or sneezing -OU: possible decreased vision, PLR present but weak, no anisocoria noted -eupnic, heart/lungs WNL -soft abdomen -slight head tilt to L -ambulatory ataxia, wide based stance in the beck -delayed proprioception on LH A 1. Seizures 2. Ataxia P -dexamethasone SP 4 mg/ml: 0.5 ml IM, gave after exam; if overall neurologic status improves, then can continue oral steroids until placement -monitor for continued seizure activity, if noted, then give 1-2 ml valium IV as needed -recommend MRI after placement -prognosis: guarded to fair; cannot rule out epilepsy but based on age and concurrent ataxia, intracranial neoplasia is a concern

Hx: Ataxia, reported seizures at the time of transport 12/22, no seizures since then. Possibly those first seizures were actually ataxic episodes? Bloodwork – unremarkable. Abd rads – no sign of metal foreign body. Pt put on trazodone on 12/23 for anxiety and stress. S: Alert, wagging tail, very friendly, allows all handling. Initially muzzled but pt flopped down on the ground when muzzled and wouldn’t get up – couldn’t perform neuro exam, so muzzle was removed. Pt gave no concerning behavior during the remainder of the exam. O: BAR-H, MMs pink and moist, BCS 6/9 EENT: No discharge OU, AU, nose. Mild tartar. H/L: NSR, NMA. Eupnic, quiet lung sounds. Abd: Soft, nonpainful, not distended, no masses palpated. M/S/I: No lesions noted. Amb x4. UG: Female spayed (tattoo visible) Neuro: Appears alert and responds appropriately to stimulation. Pt can walk, but it is difficult for her to stand up from lying down – she gets her front legs to a standing position, but has difficulty getting her back legs up. When she shakes her body, she falls over. No tremors noted. Delayed UPs (hopping) in both hind legs, L worse than R. Good CPs (paw flipping) x4 legs. A: 1. Ataxia – appears to be improving daily, even prior to steroid administration. R/O IVDD vs. FCE vs. neoplasia vs. other 2. Hx seizures – R/O episodes of ataxia vs. true seizures (epilepsy vs. neoplasia possible) 3. Change in behavior since arrival at shelter – R/O decreasing stress level vs. decrease in pain P: 1. Move out of Medical to a larger kennel – continue to monitor closely 2. Wean trazodone and attempt to discontinue it – decrease dose from 100 mg PO BID to 50 mg PO BID 3. Recommend MRI after placement 1088

Hx: ataxic, possible seizure episode on transport but suspect it may have been ataxic episode; bloodwork and xrays overall normal S/O -BAR, friendly, allows handling but prior reports of lunging when startled -good appetite -no nasal discharge or sneezing -appears to have vision but doesn’t seem to focus and has trouble tracking -intermittent mild intention tremors -slight L sided head tilt -ambulatory vestibular ataxia with high stepping gait, falls over but is able to right herself; appears stable to slightly improved from previous exam by 1382 A 1. Vestibular disease 2. Possible seizure episode-suspect related to ataxia/falling over and not true seizure P -no further treatment at this time -seizure watch, if noted then give 1.5 ml valium -recommend MRI after placement, open diagnosis at this time