IRINA – A1081543

IRINA – A1081543

FEMALE, RED, MIN PINSCHER / CHIHUAHUA SH, 6 yrs
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition EXAM REQ Intake Date 07/16/2016, From NY 11222, DueOut Date07/19/2016

Medical Behavior Evaluation BLUE
Medical Summary 07/17/16 09:59 Scan negative Brought in as stray – client claims she had two seizures while in his care (evening of 7/15 and morning of 7/16) and has been unable to use her rear legs since found outdoors. BARH – friendly, allows full exam, cries for attention BCS 4/9 Appears comfortable aside from anxiety from immobility Appetite good. No v/d/s/c. Urine/stool normal (unsure if defecating/urinating on own) EENT: Moderate calculi accumulation throughout. Moderate epiphora OU. Pupils symmetrical, PLR WNL OU. NND. Ears clean H/L auscult WNL Abd snp/nmp. Developed MG – no MGTs. Bladder full – expressed easily on palpation Perineal tone present but anal tone flaccid, low tail carriage – did not observe carrying tail on own. Aside from poor anal tone, rectal WNL – no sacral pain. Formed/Normal stool within rectum (removed). Amb x2 – attempts to stand on all 4. Unable to move rear legs. CP absent rear legs bilaterally (WNL front). Superficial pain present. Reflexes absent at rear limbs. Cutaneous trunci WNL on right side at TL junction – minimal response on left side until T2-T6 region. Grade II MPL at left stifle Cranial nerves intact, mentally appropriate. No palpable fractures. No hyperesthesia on spinal, joint, or long bone palpation. No obvious muscle wasting. No outward injuries, abrasions etc A: Hx seizures, not observed – r/o intracranial vs extracranial vs metabolic Hind limb paralysis – r/o traumatic injury vs IVDD vs neoplasia vs inflammatory (spondylitis/meningitis) vs infectious vs vascular vs other P: Attempt spinal radiographs today if time Strict crate rest Begin rimadyl 25 mg 1/2 tab PO SID x 7 days Unable to dose gabapentin appropriately here Reco rescue ASAP for further neuro work up. May need surgery for good prognosis. Potential for improvement and to regain mobility with medical management (strict rest, pain meds/anti-inflammatories, and supportive care). Will need time to assess response to treatment and prognosis (improvement can be seen within days to weeks). Unsure at this time if able to urinate/defecate on own – may need supportive care. Prognosis guarded given additional history of seizures and unknown cause for paralysis. Currently stable Keep in medical for observations, rechecks
Weight 5.4

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