MARSHMALLOW – 16864

MARSHMALLOW – 16864

Location: Manhattan; Intake Date: 12/24/17; Intake Type: Stray

Medical Behavior: Green; Sex: Male; Age: 10 years; Weight: 23 lbs

Zip Code: 10469

DVM Intake Exam; Estimated age: approx 10 years; Microchip noted on Intake? neg ; History :stray dog found in finder’s driveway, noted to have difficulty walking; good appetite ; Subjective:QAR; Observed Behavior -docile, allows all handling, good appetite; Objective ; BCS 6/9; EENT:  OU: mature cataracts; AU: mild lichenification along pinna and canals; no nasal discharge or sneezing; Oral Exam:mm pk, tacky; CRT <2 sec; moderate to severe tartar and staining; PLN: No enlargements noted; H/L: eupnic, grade III L systolic heart murmur; ABD: tense but non painful, no palpable abnormalities; had soft/normal bowel movement after exam; U/G: male intact, 2 scrotal testicles; MSI: ; -overgrown hair coat, mild matting along paws; -multiple sebaceous gland cysts; -small, soft SQ lump adjacent to prepuce, suspected lipoma; CNS:  -mentation appropriate, possible mild L sided head tilt; -ambulatory tetraparesis, occasionally falls over, stiff/stilted gait; -CP delayed on all limbs; -moderate discomfort on palpation of TL/LS spine; -severe discomfort on palpation of cervical spine, resistant to turn head to L side; Rectal: mild hypertrophy of rectum ; Assessment; 1. Tetraparetic-suspect cervical IVDD, r/o inflammatory disease vs neoplasia; 2. Heart murmur, mild; r/o valvular disease vs other; 3. Cataracts; 4. Multiple sebaceous gland cysts; 5. Suspected lipoma adjacent to prepuce; Prognosis:fair, suspect ataxia is due to herniated cervical disk; Plan:; -gave 0.5 ml hydromorphone IM, continue 0.25 ml SQ BID x 2 days; -gabapentin 100 mg PO BID x 10 days, start tomorrow; -BG 120, recommend CBC/chemistry; -gave dexamethasone 4 mg/ml: 0.2 ml IM, if improving, recommend short, tapering course of prednisone for suspected IVDD; -consider MRI after placement if signs are not improving; if doing well, then recommend activity restriction and crate rest for 4-6 weeks then gradual return to function; would likely benefit from cold laser +/- acupuncture along cervical and TL spine; -recommend chest xrays and blood pressure monitoring ; -recommend dental cleaning SURGERY:permanent waiver due to age

Let’s get to know each other a bit more…

Intake Behavior Notes:
Marshmallow had a relaxed body. He was receptive to handling and allowed to be picked up and held. He ate half a can of wet dog food. He was unable to walk but allowed the admissions counselor to transport him by carrying him.

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