THOR – 19026

THOR – 19026

**MUST HAVE PLACEMENT BY 6PM, 1/24/18**

4y Apricot Male 27lbs.  Intake: Owner Surrender 1/24/18

DVM Intake Exam; Estimated age:4 years; Microchip noted on Intake? yes; History :owner surrender, h/o panting for the last 24 hours and then acute paralysis; Subjective: BAR; Observed Behavior -excessive panting, whimpers occasionally, painful; Evidence of Trauma seen -paralyzed but no obvious trauma; Objective ; BCS 5.5/9; EENT: Eyes clear, ears clean, no nasal or ocular discharge noted; laryngeal stertor; Oral Exam: mm pk/injected, moist; CRT 2 sec; PLN: No enlargements noted; H/L: panting heavily (suspect pain), referred upper airway noise; no obvious murmurs/arrhythmias; ABD: Non painful, no masses palpated; U/G: male neutered; bladder small and soft, easily expressible; MSI:  -non ambulatory paralysis; -coat clean, good muscling; -no obvious injuries or wounds; no orthopedic abnormalities; CNS:  mentation appropriate; -non ambulatory paralysis, deep pain negative on both hind limbs, withdrawal/patellar reflex absent; Rectal: -anal tone present; -mild diarrhea staining around rectum; Assessment; 1. Paralysis-suspect disk herniation at T12/T13; Prognosis: poor for return of voluntary motor movement or ability to urinate
Plan: -gave 0.6 ml hydromorphone IM, give 0.3 ml IM BID -gave 0.2 ml dexdomitor IM for radiographs -bladder expression QID -recommend transfer to neurologist ASAP for MRI +/- hemilaminectomy; -absence of deep pain is poor prognostic indicator for ability to walk or voluntarily urinate; SURGERY: neutered

My medical notes are…

Vet Notes: 8:52 AM; 2 view spinal radiographs: collapsed disk space at T12/T13 seen on lateral and v/d; diffuse gas distension through GI tract; severe cardiomegaly noted; A; 1. Collapsed disk space, suspect disk herniation; 2. Cardiomegaly-r/o confirmation and/or radiographic technique vs DCM vs valvular disease

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