1/31/2020

DVM Intake Exam Estimated age:7 to 10 years old Microchip noted on Intake? Scanned negative History: Stray, trouble walking for 1 week Subjective: Stands and then rolls to either side Observed Behavior - Urinated on himself in exam room. Soft body for exam. Allows all handling Evidence of Cruelty seen - No Evidence of Trauma seen - No Objective 31# T = 101.4 P = 130 R = 40 BCS 8/9 EENT: Eyes clear, ears clean, no nasal or ocular discharge noted. No nystagmus. Pupils symmetric and responsive. Oral Exam: Moderate tartar and gingivitis mm pink moist crt < 2sec PLN: No enlargements noted H/L: NSR, NMA, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: Male intact, both testicles palpable in scotum MSI: Moist erythema caudal ventral abdomen and medial thighs. Dark erythema right lateral shoulder. Pink macules along right foreram. Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat CNS: Alert but seems agitated. Ataxic in all 4 limbs. Bobs and weaves head. No CP deficits. Peripheral reflexes wnl x 4. Rectal: WNL externally Assessment Severe ataxia x several days Dermatitis Possible hives. Don't appear to be bruises. Dental disease stage 3/4 Obese r/o vestibular dz vs cerebellar vs other R/o neoplasia vs toxin vs inflammatory Prognosis: Poor Plan: chem/t4/cbc 300 mls LRS SQ Cerenia 10mg/ml 1.4 ml SQ All intake tasks done. Observe in medical overnight +/- dexamethasone sp 4 mg/ml 0.5 ml SQ, antibiotics for dermatitis consider humane euthanasia if now improvement at end of stray hold SURGERY: Permanent waiver due to neuropathy

1/31/2020

Chem wnl CBC wnl T4 1.7 Pet ate wet food readily Proceed with dexamethasone SP 4 mg/ml 0.5 ml IM

2/1/2020

[Spay/Neuter Waiver - Permanent] Your newly adopted pet has been diagnosed with NEUROPATHY and the staff veterinarians are issuing a PERMANENT waiver from the spay/neuter requirements of the City of NY. ACC does not have the facility to safely sterilize your pet with his/her current condition. However, your veterinarian will provide consultation on whether this procedure can or should be performed under their supervision. Follow up care at your regular veterinarian is recommended to ensure continued treatment and proper oversight of your pet's health. All costs for follow up care and subsequent surgery is at the expense of the adopter.

2/1/2020

Hx: Stray dog, finder reported having issues with balance since finding one week ago. S: BAR, allows all handling. Eating with very good appetite O: eent: mms pink and moist, eyes clear, no ocular or nasal dc apparent h/l: heart ok no murmurs detected, lungs clear abd: abd palp nad soft and non painful lns: all pln wnl int: mild dermatitis on ventrum ms: good muscle mass in all 4 limbs, can stand for very brief periods, but then falls over neuro: severe ataxia, possible intention tremor, as has intermittent head tremor that worsens significantly when taking treats A: neuropathy-unidentified r/o infectious v toxicity v inflammatory v other ataxia obese dermatitis P: Start clindamycin course for dermatitis +/- treatment of toxoplasma or neospora. Unlikely, but will also help to treat pyoderma Clindamycin 175mg PO BID x14d

2/2/2020

Problem List: Marked ataxia Unable to walk Falls over both sides No fine control H/O had head tremor EENT- (+) menace OU; (+) palpebrals OU; (+) facial sensation; no nystagmus (resting or positional); no head tilt; slight head tremor Neuro- no CP deficits; falls over; unable to stand even with help; cannot walk ; sensation on all 4 limbs A) central lesion- cerebellar r/o infection vs other guarded to poor prognosis P) serial neuro's

2/3/2020

Problem List: Marked ataxia Unable to walk Falls over both sides No fine control H/O had head tremor PU/PD- r/o secondary to steroid RX EENT- (+) menace OU; (+) palpebrals OU; (+) facial sensation; no nystagmus (resting or positional); no head tilt; slight head tremor Neuro- no CP deficits; falls over; unable to stand even with help; cannot walk ; sensation on all 4 limbs A) central lesion- cerebellar r/o infection vs other guarded to poor prognosis P) serial neuro's does seem to have control over urination and defecation be cause waits to do functions after taken out of kennel and allowed to move around

2/4/2020

Hx: Problem List: Ataxia Unable to walk Falls over (to either side) BAR H eating eent- good swallow reflex; other cranial nerves intact; good menace and palpebral reflex hl- 120hr reg nm ss fp and e abd- overweight ug- MI msi- overweight; non-ambultory neuro- cranial nerves- intact no proprioceptive deficits falls over on both sides slinging the dog can help but still has difficulty ambulating Seems to be house trained- only defecates and urinates when removed from kennel. The problem is that he will urinate on himself because he cannot posture and walk away when going to the bathroom. pending CBC Chem thyroid panel (T4, fT4, cTSH)- unable to get urine

2/5/2020

Hx: Problem List: Ataxia Unable to walk Falls over (to either side) BAR H eating eent- good swallow reflex; other cranial nerves intact; good menace and palpebral reflex hl- 120hr reg nm ss fp and e abd- overweight ug- MI msi- overweight; non-ambultory neuro- cranial nerves- intact no proprioceptive deficits falls over on both sides slinging the dog can help but still has difficulty walking CBC Chem thyroid panel (T4, fT4, cTSH)- NSF

2/6/2020

Pet is eating and bar. Continuing to roll in urine and feces when out of cage. EENT: No nasal or ocular discharge. No nystagmus. Oral Exam: Moderate tartar and gingivitis mm pink moist crt < 2sec PLN: No enlargements noted H/L: NSR, NMA, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: Male intact MSI Ambulatory x 4, skin free of parasites, no masses noted CNS: Alert. Ataxic in all 4 limbs.No CP deficits. Peripheral reflexes wnl x 4. Rectal: WNL externally Assessment Severe & persistent Dental disease stage 3/4 Obese Pet's condition has not changed and we do not expect the ataxia to improve at this point. He needs intensive 24 nursing care to keep him clean. Prognosis grave Plan Advise humane euthanasia due to difficulty in managing him as a pet and grave prognosis.

2/7/2020

Eating, urinating and defecating. No nasal or ocular discharge. No change in neuro status. Plan EHR tomorrow if not placed.

2/8/2020

Walks about 15 steps in sling before front legs splay. Crawls and falls to both sides when left to explore room for extended periods of times. EENT: Eyes clear, ears clean, no nasal or ocular discharge noted. No nystagmus. Pupils symmetric and responsive. Oral Exam: Moderate tartar and gingivitis mm pink moist crt < 2sec PLN: No enlargements noted H/L: NSR, NMA, Lungs clear, RE wnl ABD: Non painful, no masses palpated U/G: Male intact MSI: Ambulatory x 4, healthy hair coat CNS: Alert and eager to get out of cage. Ataxic in all 4 limbs. Bobs and weaves head. No CP deficits. Peripheral reflexes wnl x 4. Obvious head tremors when he goes to eat or drink. Rectal: WNL externally Assessment Severe ataxia persists but not progressive Intention tremors Dermatitis resolved Dental disease stage 3/4 Obese r/o cerebellar vs vestibular dz R/o neoplasia vs inflammatory vs vascular accident vs other Prognosis Guarded. Pet would need intensive care in a home to keep him clean including a cart with a sling to support all 4 limbs. Plan Awaiting transport Advise humane euthanasia if transport fall through.