PRIMAVERA – 25044

PRIMAVERA – 25044

Location: Manhattan,  Intake Date: 4/12/18, Intake Type: Stray

Medical Behavior: Green,  Sex: Spayed,  Age: 12 years,  Original Location: 10453,  Weight: 8.66 pounds

DVM Intake Exam; Estimated age: Estimated 6-12 years based on dentition and arthritis; Microchip noted on Intake? Scanned POSITIVE; History : Stray, no health hx available; Subjective: Alert, looks around and tracks movements, but does not get up; Observed Behavior – Allows all handling. Doesn’t move or make a sound.  Objective ; BAR-H, MMs pink and moist, BCS 6/9; EENT: Mild mucoid discharge at medial canthus OU. Eyes clear, ears clean, no nasal discharge noted; Oral Exam: Severe tartar, gingivitis, gingival hyperplasia; PLN: No enlargements noted; H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic; ABD: Soft, distended, non painful, no masses palpated; U/G: Female, spay scar visible in muscle layer of abdomen. Small nipples. MSI: Non-ambulatory – good muscle tone but pt has no interest in standing up on any of her legs. The front legs are bent at the elbows, and the elbows are abducted slightly. The hind legs extend to the sides. Severe firm swelling in both elbows. Grade 3/4 medial patellar luxation in right stifle – moderate medial buttressing, no crepitus. With some resistance, I am able to extend pt’s hips. Skin free of parasites, no masses noted, healthy hair coat but ventral alopecia. CNS: Mentation appropriate – no signs of neurologic abnormalities; Rectal: Normal externally; Assessment: 1. Severe osteoarthritis in both elbows; 2. Hind limb lameness – cause is unclear; 3. Medial patellar luxation in right hind leg; 4. Severe dental disease; Prognosis: Poor-guarded; Plan:1. Sedate with buprenorphine 0.4 ml IM, butorphanol 0.08 ml IV and Dexdomitor 0.04 ml IV; 2. Rads of both elbows, hind legs and pelvis

My medical notes are…

Rads available for review.
Left front leg:
The bones in the shoulder are very smooth, with no sign of osteoarthritis.
The humerus, radius and ulna are all bowed.
The distal humerus, proximal radius and proximal ulna have a a large amount of irregular periosteal reaction and are abnormally shaped. The cortices of the radius and ulna are irregular near the midpoint of the bones. In particular the ulnar cortex is moth-eaten, and the radial cortex is very thin.
Right front leg:
The bones in the shoulder are very smooth, with no sign of osteoarthritis.
The humerus, radius and ulna are all bowed.
The distal humerus, proximal radius and proximal ulna have a a large amount of irregular periosteal reaction and are abnormally shaped. The cortices of the radius and ulna are irregular near the midpoint of the bones. In particular the radial cortex is very thin.
Left hind leg:
Slightly shallow acetabulum.
Irregular margins of the femoral condyles, distal patella and the tibial plateau. Joint effusion in the stifle. The patellar tendons are calcified.
The tibia is curved caudally in the middle of the bone.
The stifle is not able to be fully extended in the DP view.
Right hind leg:
Good acetabular coverage.
Margins of the femoral condyles, patella and tibia are very smooth. The patellar tendons are calcified.
The tibia is curved caudally in the middle of the bone, but to a lesser degree than on the LHL.
The stifle is not able to be fully extended in the DP view.
The tarsal bones have irregular margins and there appears to be a large amount of osteoarthritis.
On the right lateral pelvic view, there are 5 small linear curlicued metal opacities along the ventral abdomen, in the L3-L6 region.
ASSESSMENT: Severe bony deformities leading to osteoarthritis in the elbows, antebrachii, left stifle and both tarsi.
PLAN:
1. Meloxicam 1.5 mg/ml – 0.5 ml PO once, then 0.25 ml PO SID x14 days
2. If pt responds to this and will stand and walk – recommend other treatment modalities for arthritis including cold laser, acupuncture, hydrotherapy etc.

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