DVM Intake Exam Estimated age: older adult, ~ 8 yrs Microchip noted on Intake? scan positive, #985121012463325 History : owner surrender(?), history of progressively worsening ataxia/limb paralysis over the course of a week to non-ambulatory the past 2-3 days, dog seems painful and bit owner when trying to place in box for transport Subjective: Bright, alert, panting/agitated on presentation Observed Behavior – caution, will bite, seems sensitive to touch +/- painful due to medical condition Evidence of Cruelty seen – heavy matting around all four limbs Evidence of Trauma seen – no Objective T = 100.5 P = 104 R = panting BCS 8/9 EENT: OU clear, nsf, no discharge present; AU clean; no nasal or ocular discharge noted Oral Exam: mild tartar PLN: No enlargements noted H/L: NSR, NMA, CRT < 2; Lungs clear, eupnic ABD: tense, unable to examine until sedated U/G: neutered male, large soft bladder (unable to express – owner reports urinating at home) MSI: *limited exam due to patient temperament/pain* amb x 1, presented unable to walk and only possessing motor in his front left leg, right front paw was in extension and non-moving but has some sensitivity to stimulation/deep pain, both rear legs held flexed, appear to maintain deep-pain response and withdrawal but no motor – hair around all legs was heavily matted (but not casting/no lesions) and has an ingrown nail on the first digit of right rear paw; skin free of parasites, no masses noted, mod. dirty/unkempt coat with pieces of debris CNS: Mentation appropriate – no signs of neurologic abnormalities except for previously described right front limb paralysis and hind limb paresis Rectal: maintains tone (owner reported defecating at home) Sedated for rads, blood collection and cath. placement Rads: no obvious signs of trauma/injury to spine/extremeties – food in stomach, large amount of feces in intestine/colon – poss. enlarged spleen – obese – large bladder CBC/Chem: unremarkable (slightly decreased HBC) A: ataxic with right front-limb paralysis, hind-limb paresis; this condition appears progressive and there is great concern if cause cannot be addressed and corrected (and/or does not respond to treatment), the prognosis continues to worsen r/o disc degeneration (acute/chronic), FCE/vascular anomaly, neoplasia, trauma, infect/inflamm vs other – matted coat – ingrown nail Tx: IV cath placed, maint. on LRS 30 ml/hr – Hydro 0.6 ml IV – Dex Sp 0.3 ml IV – Cerenia 1.2 ml IV P: cont. supportive care in medical and will reassess overall status in 24 hrs – needs further diagnostic work-up to determine cause – has very guarded prognosis for ability to walk again/make substantial recovery, esp. the longer his condition persists rec’ placement deadline for 6 pm tonight; medical will reassess and may EHR due to poor condition/prognosis Px: guarded – poor SURGERY: neutered

Recheck in med for progressive paresis/ataxia: S/O: Quiet, alert, panting – slight clear nasal discharge – siting up in kennel, will try to bite if moved/handled – able to sling hind legs up with a towel but remains non-ambulatory on right front and rear legs, only tries to stand on left front leg A: condition appears the same; decr. LRS to half maint. @ 15 ml/hr overnight P: cont. supportive care and reassess in AM

Hx: presented with severe, non ambulatory paresis with motor movement only in RF; owner reported signs progressed over several days until he was no longer ambulatory; given dexamethasone injection and started on hydromorphone and IVF S/O -BAR, interactive; allows gentle petting but performed limited exam -mild serous nasal discharge, no sneezing or coughing -eupnic, quiet lung sounds -urinated large amount of clear/yellow in cage -no appetite but seems interested -ambulatory today!! severe paresis with RF lameness but able to stand and walk; mild extensor rigidity in hindlimbs -appears comfortable today, did not palpate spine today but allows petting along spine; appears to have good cervical ROM -overweight A 1. Severe paresis, improving-r/o IVDD vs inflammatory (meningitis) vs FCE vs other 2. RF lameness-suspect neurologic; r/o root signature vs IVDD vs meningitis vs other 3. Overweight P Continue hydromorphone IV 0.3 ml q4h Recommend MRI immediately after placement If still here tomorrow, then consider continuing steroid therapy orally prognosis: guarded to fair; neurologic status appears significantly improved today but we are unsure of the underlying cause of the signs at this time; it is likely a disk herniation but could be inflammatory disease which may require long term management

S/O -BAR, allows gentle handling -mild appetite -panting, likely secondary to recent hydromorphone administration -serous nasal discharge, no sneezing or coughing noted -OU: mild mucoid d/c -eupnic -strong ambulation today! still has residual paraparesis but improved from yesterday; RF lameness also improving A 1. Paraparesis-r/o TL or cervical IVDD vs inflammatory dz vs other 2. RF lameness-r/o root signature vs IVDD lesion vs inflammatory dz vs orthopedic P d/c hydromorphone gabapentin 100 mg PO BID x 14 days prednisone 5 mg PO BID x 2 days, 5 mg SID x 4 days, then 5 mg EOD x 4 doses prognosis: fair to good; ambulation has improved significantly and he seems overall comfortably, however and MRI is still recommended after placement to determine the cause of the signs; if there is a disk herniation, surgery may indicated to improve long term success

Hx: Admitted 12/9 with paralysis of RFL and both hind legs – deep pain stimulation present in all legs. Has been receiving pain medication and steroids. Pt has made amazing improvements in motor function of RFL and hind legs! Good appetite this morning S/O: Alert, BCS 8-9/9, nips when I touch RFL, allows limited exam Walks really well on hind legs! Somewhat lame on RFL Unable to perform neurological exam of legs due to behavior A: Neurological disease of RFL and both hind limbs – dramatic improvement in just a few days – R/O IVDD vs. FCE vs. other P: Continue treatments as scheduled 1088

Hx: presented with non-ambulatory tetraparesis with motor movement on in RF; was given dexamethasone injection and within 24 hours was strongly ambulatory; was continued on oral prednisone at 5 mg PO BID x 2 days, today is first day of taper at 5 mg SID S/O -BAR, friendly and allows handling with me -mm pk, sl tacky; CRT <2 sec -mild appetite -clear, sl mucoid ocular discharge, no irritation -eupnic -ambulatory x 4 but seemed more ataxic than yesterday, which has progressed through the day -this afternoon, he was non weight bearing on RF; limb in state of rigid flexion A 1. Tetraparesis, improved initially but appears to be worsening again 2. LF lameness, new; different limb than forelimb lameness on presentation P -Dexamethasone 4 mg/ml: 0.3 ml SQ today -Increase prednisone dose to 10 mg PO SID, okay to do SID dosing due to difficulty in administering oral medication -Recommend transfer to neurologist ASAP for MRI +/- spinal tap; due to regression through the day as well as new LF lameness that appears neurologic in nature, there is a higher concern for inflammatory disease such as meningitis rather than disk disease -may need to have wash-out period in between last steroid dose and further diagnostics but this should be at the neurologists discretion; will continue steroid therapy in shelter due to concern of deterioration without

Hx: presented non-ambulatory tetraparetic with voluntary motor only in RF; after dexamethasone injection and hydromorphone, he was strongly ambulatory and continued to improve over 48 hours; however, yesterday he appeared more ataxic with a new LF lameness; dexamethasone injection repeated yesterday, continued on oral prednisone and gabapentin but he is difficult to medicate S/O -BAR, very excited to see me! panting and barking anxiously in his cage to come out; has become much easier to handle and loves sitting in my lap during his exam -good appetite with soft food -mild serous nasal discharge, no sneezing or coughing noted -OU: open and clear -panting initially, seems anxiety/behavioral related more than pain -eupnic, normal lung sounds, no murmur noted -ambulatory with mild to moderate ataxia -delayed proprioception on RF and RH, normal on L side -LF: non weight bearing lameness/paresis but will intermittently put limb down; limb appears hyperflexed A 1. Ataxia, hemiparesis R side 2. LF lameness/paresis P -strict cage rest, no walks outside or neck leads -recommend release to transfer to neurologist ASAP due to concern for further deterioration in shelter; neurologic abnormalities may be due to cervical disk herniation or inflammatory disease (r/o thoracic disk herniation vs other) and may require surgery or additional medications pending results of MRI

To Whom it May Concern, Rico is an approximately 8 year old male neutered mixed breed dog that presented to MACC with progressive severe, tetraparesis that is likely related to a herniated disk. He is currently on a DOH hold after biting two his owner and the admitting veterinarian. It is very likely that the bites were in response to significant discomfort secondary to his condition. He has since allowed handling with minimal concerns. His signs improved significantly within the first 24 hours and continued to improve for several days, at which time his they appeared almost resolved. However, within the last 48 hours, his condition has deteriorated somewhat. Although he is stable, I am concerned that without further follow up care including an MRI to confirm the diagnosis, his condition will continue to deteriorate. I do not feel that it is medically appropriate to continue treatment in the shelter until his hold is off and I would appreciate your consideration for an early release on his hold. Sincerely, Erika Elmore, DVM, CCRT

Hx: presented non-ambulatory tetraparetic with voluntary motor only in RF; after dexamethasone injection and hydromorphone, he was strongly ambulatory and continued to improve over 48 hours; however, yesterday he appeared more ataxic with a new LF lameness; dexamethasone injection repeated yesterday, continued on oral prednisone and gabapentin but he is difficult to medicate S/O -Did well overnight, no reported concerns. -BAR, excited and hyper in cage, readily came out. Muzzled for exam, did try to bite -No c/s/v/d, normal U/BM, and eating well. -Ambulatory x 4, mild ataxia noted. Delayed CP’s in RFL and RHL, normal CP LHL, unable to assess LFL as p would not allow. P is able to place weight on LFL but does hold leg up when sitting. -Subjectively comfortable. -H/L: wnl A 1. Ataxia, hemiparesis R side 2. LF lameness/paresis P -continue prednisone 10 mg PO SID (last dose scheduled 12/18), okay to do SID dosing due to difficulty in administering oral medication -continue gabapentin 100mg PO BID x 14d, until 12/25 -strict cage rest, no walks outside or neck leads -recommend release to transfer to neurologist ASAP due to concern for further deterioration in shelter; neurologic abnormalities may be due to cervical disk herniation or inflammatory disease (r/o thoracic disk herniation vs other) and may require surgery or additional medications pending results of MRI -Early termination of DOH bite hold (so that p can be transferred to a neurologist) denied. On bite hold until Tuesday 12/19. Keep p comfortable until bite hold is up and p can be transferred. If p’s condition deteriorates before bite hold is up, consider humane euthanasia.

Recheck in medical for hx of ataxia: S/O: QARH – limited palpation/PE due to history and did not try to bite – e/d well u/d well – no c/s or v/d – H/L nsf – amb x 4, remains mildly ataxic in rear legs, mild weakness, stumbles when trying to lift leg to urinate but overall much improved since intake A: condition/ataxia stable P: CWCT

Hx: presented 12/9/17 non-ambulatory tetraparetic with voluntary motor only in RF; after dexamethasone injection and hydromorphone, he was strongly ambulatory and continued to improve over 48 hours; however, yesterday 12/13 he appeared more ataxic with a new LF lameness; dexamethasone injection repeated 12/13, continued on oral prednisone and gabapentin but he is difficult to medicate. S/O -Did well overnight, no reported concerns. -BAR, excited and hyper in cage, readily came out on own -No c/s/v/d, normal U/BM, and eating well. -Ambulatory x 4, mild ataxia noted when p first starts to walk but then improves. Intermittently holds up LFL vs walking on it normally. CP’s present and normal x 4 -P appears comfortable. Does not like FL’s being touched, does try to bite. -H/L: wnl A 1. Ataxia, hemiparesis R side — improving 2. LF lameness/paresis — intermittent P -continue prednisone 10 mg PO SID (last dose scheduled 12/18), okay to do SID dosing due to difficulty in administering oral medication -continue gabapentin 100mg PO BID x 14d, until 12/25 -strict cage rest, no walks outside or neck leads -recommend release to transfer to neurologist ASAP due to concern for further deterioration in shelter; neurologic abnormalities may be due to cervical disk herniation or inflammatory disease (r/o thoracic disk herniation vs other) and may require surgery or additional medications pending results of MRI -Early termination of DOH bite hold (so that p can be transferred to a neurologist) denied. On bite hold until Tuesday 12/19. Keep p comfortable until bite hold is up and p can be transferred. If p’s condition deteriorates before bite hold is up, consider humane euthanasia.

Gabapentin capsule found in cage, suspect did not get morning or evening dose yesterday S/O -QAR, seems less interactive today -mm pk/pigmented, sl tacky -mild appetite -no nasal discharge or sneezing -eupnic -ambulatory tetraparesis/ataxia with non weight bearing LF limb; ataxia appears worse today than yesterday but still strongly ambulatory; slightly high stepping gait A 1. Tetraparesis-r/o cervical IVDD vs other 2. LF lameness, suspect related to neuro condition P -today is last day of prednisone 10 mg SID, will extend this dose for another 48 hours and then try to taper to 5 mg SID -hydromorphone 0.3 ml SQ, gave at 9 am -recommend referral to neurologist ASAP after placement for MRI, suspect cervical disk; may require surgery and/or aggressive medical treatment (crate rest, activity restriction, pain management x 8 weeks, cold laser therapy, +/- rehabilitation) -suspect LF lameness is related to neurologic condition and may coincide with discomfort as it appears to be intermittent and because he is difficult to medicate, he may not always eat medication in food

S/O -BAR, gets very anxious and excited in the morning to come out of the kennel -moderate appetite, taking meds with chicken -mm pk/pigmented, sl tacky -soft sneezed once, no significant nasal discharge -OU: crusting discharge in fur at medial canthus -eupnic -soft abdomen -ambulatory tetraparesis but appears stable to slightly improved from yesterday; persistent LF lameness but limb appears less flexed today -delayed CP x 4 A 1. Tetraparesis, stable 2. LF lameness, suspect related to neurologic issue P Continue gabapentin, prednisone Recommend transfer ASAP to neurologist for MRI; suspect disk herniation which has improved significantly but surgery may be indicated to improve long term success; otherwise consider rehabilitation with cold laser therapy +/- acupuncture and underwater treadmill

S/O -BAR, very energetic in kennel this morning to come out -urination and had normal bowel movement on walk -mm pk/pigmented, moist -good appetite -soft sneezed once -strongly ambulatory with mild ataxia, occasionally slips -LF, non weight bearing lameness/paresis; will bear weight on limb when urinating -delayed CP on forelimbs A 1. Tetraparesis, mild, stable 2. LF lameness/paresis 3. Soft sneezing-r/o behavioral vs early CIRDC P CWCT Monitor for URI

S/O -BAR, energetic and excited -good appetite -mm pk/pigmented, sl tacky -scant serous nasal discharge, no sneezing or coughing noted this morning -eupnic -strongly ambulatory today but still non weight bearing on LF; will place it down and bear weight for brief periods of time -light brown liquid diarrhea with small amount of blood tinged A 1. Tetraparesis, significantly improved from intake 2. LF lameness/paresis 3. Diarrhea-r/o stress vs treats vs other P -metronidazole 250 mg PO SID x 7 days -continue prednisone and gabapentin -recommend MRI after placement to definitively diagnosis underlying condition; if disk herniation, then treatment options include surgery vs medical rehabilitation

Upon intake Rico was in the box. He scanned positive for a microchip and no handling was done due to condition of dog.

Date of intake:: 12/9/2017

Spay/Neuter status:: Yes

Means of surrender (length of time in previous home):: Owner surrender (in home for 2 months)

Bite history:: Yes. Rico bit his owner when the owner was placing Rico into a box for transport to the shelter seeking medical care. The bite resulted in 3 puncture wounds to the right hand. Rico bit a second time during a veterinary examination in the shelter. This bite resulted in a puncture to the left thumb. Both injuries were self-treated.

Summary:: Due to Rico’s medical condition and apparent pain response he is not a candidate for a handling assessment at this time.

Date of intake:: 12/9/2017

Summary:: Rico was not handled due to his medical condition.

Date of initial:: 12/9/2017

Summary:: Sensitive to touch, concerns about biting voiced by staff

IN SHELTER OBSERVATIONS:: We’re unsure how much of Rico’s medical condition is influencing his behavior, however, he has shown signs of discomfort when out on walks despite our best efforts to provide him with quality walks. Handler had to place and hold a “sling” around his hind legs and position his back legs perpendicular to his body in order for him to walk properly. Due the fact that he kept falling over and he snapped at the sling when it was misplaced, Rico’s interactions have been limited.

BEHAVIOR DETERMINATION:: NEW HOPE ONLY

Behavior Asilomar: TM – Treatable-Manageable

Recommendations:: Place with a New Hope partner

Recommendations comments:: Due to Rico’s current medical condition we are unable to fully assess his behavior. He has bitten twice in recent days, possibly in response to a painful condition. We recommend placement with a New Hope partner who can address his medical condition and then re-evaluate his behavior in a stable home environment after recovery.

Potential challenges: : Handling/touch sensitivity,Fearful/potential for defensive aggression