11/22/2017

[DVM Intake] DVM Intake Exam Estimated age: 3 yo Microchip noted on Intake? n History : Pt left behind when owner moved Subjective: BAR, non-ambulatory in hind Observed Behavior - friendly, easily handled Evidence of Cruelty seen - n Evidence of Trauma seen - n Objective T = 99.8 P = 100 R = 20 BCS 4/9 EENT: Eyes clear, ears clean, no nasal or ocular discharge noted Oral Exam: pink mm w/ CRT< 2s, mild tartar PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: no spay scar noted, malodorous urine MSI: Ambulatory x 2,absent proprioception in hind, deep pain present, no overt pain on spinal palpation, mild discomfort on cervical extension, skin free of parasites, no masses noted, healthy hair coat CNS: Mentation appropriate - absent proprioception in hind, reflexes present, anal tone present Rectal: very dry feces Assessment: 1. Hindlimb paraparesis - DDX: trauma vs IVDD vs congenital malformation 2. Suspect UTI (secondary to retention) Prognosis: Fair Plan: 1. spinal x-ray 2. bloodwork- cbc/chemistry 3. Clavamox 62.5: 1 tablet PO BID x 10 days 4. Dexemethasone injection (pending test results) 5. Prednisone 5 mg: 1 tablet PO BID x 7 days, then taper pending improvement SURGERY: Temporary waiver due to neurological status

11/24/2017

Recheck hind end paresis History - presented on 11/22, started on clavamox and prednisone S/O: Q/BARH. Attention seeking, allows all handling. BCS 5/9 EENT: Eyes clear, no ocular or nasal discharge, ears wnl, pink mm, mild to moderate dental tartar HL: Normal thoracic auscultation ABD: Soft, non tender; large soft bladder, easily expressed concentrated urine INTEG: WNL MS: Dragging hind limbs, deep pain present, decreased motor UG: Female A: Hind end paresis - R/O: IVDD vs trauma vs other, NSF on radiographs at intake P: Continue with current treatment and monitoring plan. Rec full neurology work up including advanced imaging.

11/25/2017

Monitor condition - hind end paresis History - presented on 11/22, started on clavamox and prednisone S/O: BARH. Attention seeking, allows all handling. Excellent appetite. Clean cage, no stool or urine noted. BCS 5/9 EENT: Eyes clear, no ocular or nasal discharge, ears wnl, pink mm, mild to moderate dental tartar HL: No coughing or sneezing ABD: Soft, non tender; small soft bladder, easily expressed urine INTEG: WNL MS: Dragging hind limbs, deep pain present, decreased motor, no pain elicited on palpation, appears comfortable with all handling UG: Female A: Hind end paresis - R/O: IVDD vs trauma vs other, NSF on radiographs at intake; ability to control eliminations questionable P: Continue with current treatment and monitoring plan. Rec full neurology work up including advanced imaging. Fair/open prognosis depending on diagnostic findings

11/26/2017

Progress exam History : Intake 11/22-paraplegic.Started on clavamox and prednisone, given one dose of dexmethasone. CBC-nsf Chem-nsf Subjective: BAR, paraplegia but seems stable. Eating well and very friendly. Unable to express bladder on own-must be expressed BID. No c/s/v/d. Firm feces in cage. Objective P = wnl R = wnl BCS 4/9 EENT: Eyes clear, ears clean, no nasal or ocular discharge noted Oral Exam: adult dentition with mild tartar PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic ABD: Non painful, no masses palpated, bladder moderate sized and soft U/G: FI, no vulvar d/c, no MGTs, bladder expressed easily MSI: Ambulatory x 2, skin free of parasites, no masses noted, healthy hair coat CNS: Mentation appropriate - paraplegia with positive deep pain and withdrawal, absent CPs, FL wnl, able to drag body around on FLs, anal tone present but unable to express her bladder on her own-must be manually expressed Assessment: Paraplegia - DDX: trauma vs IVDD vs congenital malformation Suspect UTI (secondary to retention) Prognosis: Guarded-will need manual expression of bladder, possibly for the rest of her life Plan: CTM while at BACC Express bladder BID Continue Clavamox until 12/6 Continue Prednisone 5 mg: 1 tablet PO BID until 11/29, then taper pending improvement Continue tramadol until 11/29 Rec neurology consult with imaging (MRI)-will likely need surgery

11/27/2017

Progress exam History : Intake 11/22-paraplegic.Started on clavamox and prednisone, given one dose of dexmethasone. CBC-nsf Chem-nsf Subjective: BAR, paraplegia but seems stable. Eating well and very friendly. Unable to express bladder on own-must be expressed BID. No c/s/v/d. Objective P = wnl R = wnl BCS 4/9 EENT: Eyes clear, ears clean, no nasal or ocular discharge noted Oral Exam: adult dentition, prognathism PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic ABD: Non painful, no masses palpated, bladder moderate to large sized and soft U/G: FI, no vulvar d/c, no MGTs MSI: Ambulatory x 2, skin free of parasites, no masses noted, healthy hair coat CNS: Mentation appropriate - paraplegia with positive deep pain and withdrawal, absent CPs, FL wnl, able to drag body around on FLs Assessment: Paraplegia - DDX: trauma vs IVDD vs congenital malformation Suspect UTI (secondary to retention) UMN bladder Prognosis: Guarded-will need manual expression of bladder, possibly for the rest of her life Plan: CTM while at BACC Express bladder BID Continue Clavamox until 12/6 Continue Prednisone 5 mg: 1 tablet PO BID until 11/29, then taper pending improvement Continue tramadol until 11/29 Rec neurology consult with imaging (MRI)-will likely need surgery

Nina allowed being petted and picked up. Nina was very friendly and affectionate.