CATTY – A1035163
Safe 5-12-2015 Brooklyn Rescue: New Jersey Schnauzer Animal Rescue Please honor your pledges: http://njsrn.org/
SAFE – 05/12/15
CATTY – A1035163
**INJURED! NEEDS TO LEAVE FOR A VET BY TOMORROW MORNING!**
SPAYED FEMALE, BLACK / WHITE, CAIRN TERRIER MIX, 8 yrs
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition INJ SEVERE Intake Date 05/03/2015, From NY 11419, DueOut Date 05/06/2015,
Medical Behavior Evaluation GREEN
Medical Summary Scan negative F; 8 YO; 11.9 LB Calm during exam Came in as poss HBC Examined by 1044 (see cage exam) BARH Actyvil applied
Weight 11.9
Profile:
Client came in with stray dog she found 2 days ago. Client said dog has been unreasponsive and doesnt eat or drink.
Basic Information
Catty came in as a stray, finder has no known personality or behavior on this dog.
Behavior during intake
Catty was in finders arms and was quiet allowed scanning.
As per finder dog was found on street and she tried to feed but has not eaten or drank in 2 days . Dog also does not move stiff limbs. Finder stated dog is unresponsive to things around him.
MEDICAL:
5/3:
S/O: CAME FROM QUEENS, LETHARGIC/LATERAL RECUMBANCY, SCAN NEGATIVE
EENM: MM PINK AND MOIST, CRT 2 SEC, MODERATE GINGIVITIS AND CALCULI
CV: QUIET,NO MURMURS OR ARRHYTHMIAS
LUNGS: CLEAR
ABD: TENDER
MS/INTEG: AMB X 4, BCS 5/9, APPEARS TO BE RECENTLY SHAVED
NS: HOLDING UP LFT, NO FRACTURES, THEN PLACED, BILATERAL HL ATAXIA AND CP DEFICITS, DEEP PAIN POSITIVE, PAINFUL T13-L5 APPROXIMATLEY, CERVICAL MANIPULATION MAY BE PAINFUL
PLN: NSF
GU: SPAYED FEMALE, SCAR PALPABLE
A:
HL ATAXIA AND CP DEFICITS, LUMBAR PAIN
DDX: IVD VS PROTRUSION/HERNIA VS OTHER
P:
BUPRENEX 0.32 CC SQ BID X 5 DAYS
CONTACT NEW HOPE ASAP (ALREADY LEFT TODAY)
GUARDED TO FAIR PROGNOSIS AT THIS TIME
CONTINUE TO MONITOR
5/4:
Hx: came in late last night, likely spinal injury. Was ataxic but walking last night. No interest in food or water today.
S: Quiet, lateral or sternal recumbency, quivers and cries out when picked up, responsive to touch and speech
O: QAR, BCS 4.5/9, MMs pink and moist
EENT: Mild mucoid discharge OU. Saliva in dependent side of mouth (was in lateral recumbency prior to exam). No dschg AU, nose. Mild dental tartar and gingivitis.
H/L: NMA, NSR, eupnic
PLNs: None enlarged
Abd: Abd slightly tense
M/S/I: Weak. Cannot walk today. No external lesions noted.
Neuro: Alert, responsive. No response to paw flip in left hind or left front but positive response in right hind and right front. Patellar reflexes intact both sides. Hopping not tested. Pt cannot stand without assistance.
U/G: Female, spay tattoo visible on abdomen. Pt spontaneously urinated a large volume when abdomen was palpated (i.e. not actively expressed).
2-view spinal rads: no abnormalities seen in M/S or soft tissue systems
A:
1. Neurological injury T3-L3
2. Left front leg pain – possible root sign L front leg
3. Needs assistance expressing bladder
4. Likely dehydrated (MMs mucous covered)
Short-term prognosis: Fair to guarded prognosis
P:
1. Continue buprenorphine
2. Place IVC and start IVF at 20 ml/hr; decrease to 15 ml/hr at 8pm
3. Rec pt leave for continued vet care by tomorrow
4. Offer food and water to face directly q8
5. Palpate abdomen and express bladder if necessary q8
1088
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