EMPIRE – A1054791
Safe 10-19-2015 Manhattan Rescue: Amsterdog Animal Rescue Please honor your pledges: http://amsterdog.org/donate/
SAFE 10/19/15
Manhattan Center
My name is EMPIRE. My Animal ID # is A1054791.
I am a male black and white shih tzu mix. The shelter thinks I am about 7 YEARS old.
I came in the shelter as a STRAY on 10/14/2015 from NY 10457, owner surrender reason stated was STRAY.
MOST RECENT MEDICAL INFORMATION AND WEIGHT
10/17/2015 Exam Type RE-EXAM – Medical Rating is 4 NC – SEVERE CONDITIONS NOT CONTAGIOUS, Behavior Rating is NONE, Weight 12.5 LBS.
10/17/15 12:52 S/O: physical exam unchanged. eating well, appears comfortable. able to walk but very ataxic, good strength. A: neuro disease, ataxia P: needs new hope placement, fair to gaurded prognosis due to advanced age 10/16/15 10:06 S/O: eating well and appears comfortable. non-painful on spinal palpation and has normal ROM in neck. continues to have left sided head tilt and falls/leans to the right. able to walk better today, less weak, but still ataxic. difficult to assess CP’s due to imbalance when standing. no nystagmus. A: neurologic disease – r/o neoplasia (brain tumor) vs. infectious/inflammatory vs. idiopathic vs. trauma vs. inner ear disease vs. vascular infarct P: continue cerenia and baytril needs NH placement for neuro work up (MRI would be best) 10/15/15 10:06 S/O: geriatric intact male, friendly and allows exam, severe dental disease and nuclear sclerosis, very good appetite for wet food, mild dehydration. falling toward right side, will stand with assistance and walk a few steps with very stilted/ataxic gait. slight left sided head tilt. no nystagmus (tried turning over on his back to induce and still no nystagmus). BAR, and barking in cage for attention. appears comfortable and non-painful on spinal palpation. no evidence of trauma. A: neurologic disease – r/o neoplasia (brain tumor) vs. infectious/inflammatory vs. idiopathic vs. trauma vs. inner ear disease vs. P: continue to monitor neurologic signs (seems to be slightly improved compared to yesterday) continue cerenia continue baytril consider adding steroids if signs worsen or do not improve with current treatments prognosis – fair to guarded. depends on the cause…due to his advanced age neoplasia is a top differential
10/14/2015 PET PROFILE MEMO
10/14/15 12:03 BASIC INFO Empire A1054791 is an approximately 7 year old Shih Tzu Mix. He was found in the stairwell, leading to the roof top of Finder’s building. Finder cannot keep as they have a dog of their own. Finder picked him up in a blanket and brought here. BEHAVIOR DURING INTAKE Empire was dull and depressed during intake and could not stand up.
WEB MEMO
No Web Memo
10/17/2015 BEHAVIOR EVALUATION – NH ONLY
Exam Type BEHAVIOR
Due to the possibility of discomfort as a result of the handling, his overall medical condition, and our desire to decrease stress in the care center, the behavior department believes that Empire is not an appropriate candidate for SAFER at this time. Empire did display geriatric and lethargic behavior upon intake, but did allow the medical staff to handle him without displaying any signs of aggression.
GROUP BEHAVIOR EVALUATION
No Group Behavior Summary
10/14/2015 INITIAL PHYSICAL EXAM
Medical rating was 4 NC – SEVERE CONDITIONS NOT CONTAGIOUS, behavior rating was NONE
MC scanned – negative Intact male small dog, estimated age 7 years old Hx: Found in a stairwell inside an apartment building S: Calm, quiet, allows all handling including exam and IV catheter placement. O: BAR, moderately decreased skin turgor, 8% dehydrated. BCS 2.5/9, MMs pink and tacky EENT: No discharge OU, AU, nose. Moderate tartar and gingivitis. PLNs: Not enlarged. H/L: HR 152, NSR, NMA. RR 32, quiet lung sounds. Abd: Moderately tense, no pain on palpation, no masses palpated M/S/I: Laterally recumbent, cannot walk even when held in a standing position. Small firm dermal masses caudal to left elbow (1 cm dia), and at left hip (2 cm dia). Muscle wasting in hind legs. Long nails on hind legs. UG: Male intact, testicles soft and symmetrical Neuro: Pt is alert and responsive to verbal and visual stimuli. When lying down, pt rolls onto right side, with hind legs held straight up in the air. When held in a standing position, pt curls to the right side. No nystagmus. Good sensation in all four feet. A: 1. Rolling to right – vestibular disease, R/O central vs. peripheral. Trauma, infection, idiopathic, other. Pt is an unusual breed and age for geriatric vestibular disease (typically large-breed older dogs). 2. Dehydration 3. Underweight 4. Dental disease Short-term prognosis: Fair to poor, depending on pt does in the next 1-2 days. P: 1. Did not vaccinate or give dewormer. Applied Activyl. 2. Started IVC and gave 200 ml LRS bolus 3. Transport to MACC for further care 1088
10/17/2015 RE-EXAM (LAST MAJOR EXAM)
Medical rating 4 NC – SEVERE CONDITIONS NOT CONTAGIOUS,
10/17/15 12:52 S/O: physical exam unchanged. eating well, appears comfortable. able to walk but very ataxic, good strength. A: neuro disease, ataxia P: needs new hope placement, fair to gaurded prognosis due to advanced age 10/16/15 10:06 S/O: eating well and appears comfortable. non-painful on spinal palpation and has normal ROM in neck. continues to have left sided head tilt and falls/leans to the right. able to walk better today, less weak, but still ataxic. difficult to assess CP’s due to imbalance when standing. no nystagmus. A: neurologic disease – r/o neoplasia (brain tumor) vs. infectious/inflammatory vs. idiopathic vs. trauma vs. inner ear disease vs. vascular infarct P: continue cerenia and baytril needs NH placement for neuro work up (MRI would be best) 10/15/15 10:06 S/O: geriatric intact male, friendly and allows exam, severe dental disease and nuclear sclerosis, very good appetite for wet food, mild dehydration. falling toward right side, will stand with assistance and walk a few steps with very stilted/ataxic gait. slight left sided head tilt. no nystagmus (tried turning over on his back to induce and still no nystagmus). BAR, and barking in cage for attention. appears comfortable and non-painful on spinal palpation. no evidence of trauma. A: neurologic disease – r/o neoplasia (brain tumor) vs. infectious/inflammatory vs. idiopathic vs. trauma vs. inner ear disease vs. P: continue to monitor neurologic signs (seems to be slightly improved compared to yesterday) continue cerenia continue baytril consider adding steroids if signs worsen or do not improve with current treatments prognosis – fair to guarded. depends on the cause…due to his advanced age neoplasia is a top differential
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