NELLY – A1040866
NELLY – A1040866
MALE, BLACK / WHITE, DOMESTIC SH,5 yrs
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition ILLNESS Intake Date 06/20/2015, From NY 11413, DueOut Date06/23/2015,
Medical Behavior Evaluation GREEN
Medical Summary Scan negative Approx 5 years Intact male BAR, vocalizing frequently Unknown history Lifts head and able to sit sternally, but won’t attempt to stand or adjust hind limbs Very good appetite mm = pink, moist, CRT< 2sec. hydration = slightly prolonged skin tenting (approx. 5% deydrated) Integ = Multiple small scabs over outer pinnae, and around face; dirty coat EENT = clear OU, Mild to mod. debris AU; nnd, Moderate periodontal disease H/L = low grade heart murmur heard loudest on the the left (difficult to auscult well due to tachypnea); increased BV sounds, bilaterally – no crackles or wheezes. Abdomen = snp, kidneys large, symmetrical (likely due to being intact) LN = wnl CNS = appropriate MS = non-ambulatory on hind ends – motor functional x 4; hind limbs palpate stiff. BCS: 5/9 No palpable fractures A: hind limb paresis – r/o spinal fracture/trauma vs. IVDD vs. TE vs other heart murmur otitis externa AU periodontal disease old wounds on face/ears mild dehydration Px: Guarded P: Abdominal and thoracic radiographs taken – mild lack of serosal detail in abdomen. Formed feces in colon, mild gas opacity within cranial abdomen (stomach). No obvious abnormalities to spine or extremities. Combo test: FIV POSITIVE Administered 0.16 mL Loxicom SQ (0.3mg/kg) Administered 0.16 mL Buprenex SQ (0.03 mg/kg) Pyrantel administered Vaccinated Provided heat support in cage 100 mL LRS SQ Re-examinetomorrow. Currently on stray hold but recommend New Hope placement once off stray hold if still not ambulatory.
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