FRANK – A1034020

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FRANK – A1034020

I am an unaltered female, black Domestic Shorthair mix.

The shelter staff think I am about 1 year old.

I weigh 5 pounds.

I was found in NY 11221.

I have been at the shelter since Apr 22, 2015.

FEMALE, BLACK, DOMESTIC SH MIX,1 yr
OWNER SUR – EVALUATE, NO HOLD Reason PERS PROB
Intake condition UNSPECIFIE Intake Date 04/22/2015, From NY 11221, DueOut Date 04/22/2015, I came in with Group/Litter #K15-010984.

Medical Behavior Evaluation GREEN

Medical

Initial: Green

scan negative

female, 1 year

easy to handle for exam

rotary nystagmus, fast phase to left

vocalizing

head tilt & turn to right

circling L & R

purring

None of these symptoms presented yesterday during vaccination

no activyl applied per 1088

 

Re-exam: 4/23

Hx: Did not have vestibular signs yesterday when vaccinated; today pt has vestibular signs during intake exam.

 

S: Easy to handle, meowing, purring quietly

 

O: BCS 4.5/9. BAR-H, MMs pink and moist, CRT < 2 sec

EENT – No dschg OU, AU, nose. Normal fundic exam. Clean teeth.

H/L – NSR, NMA. Eupnic. Quiet lung sounds.

PLNs – Not enlarged

Abd – Soft, no pain on palp, no masses palpated.

M/S/I – Amb x4, no skin lesions noted.

UG – Female

 

Neuro: Appears to be alert and oriented, responding to environment normally.

CN 1 (olfactory) ?

CN 2 normal direct and consensual PLRs OU

CN 3 normal PLRs, no strabismus

CN 4 no eye rotation

CN 5 normal jaw tone, normal muscle mass on head

CN 6 no strabismus

CN 7 normal blinking, no facial droop

CN 8 ABNORMAL – pt has head tilt to right, is circling to R (occasionally turns to left, but then turns back to R and circles to R), rotary nystagmus with fast phase to left

CN 9 normal gag reflex, not drooling

CN 10 normal gag reflex

CN 11 normal muscle mass

CN 12 normal tongue strength

Pt is not ataxic and has normal limb reflexes

 

CBC: eosinopenia (0.03), normal WBC ct, normal Hct, *NO PLATELETS SEEN*!

Chem: decreased BUN (13), decreased creat (0.6), elevated GGT (3)

 

A:

1. Vestibular signs

R/O peripheral vestib dz (more likely given rotary nystagmus) – causes include otitis interna/media, feline idiopathic vestibular disease, nasopharyngeal polyp, trauma, neoplasia

R/O central vestib dz – causes include infectious (incl. FIP), trauma, neoplasia, infarct, metronidazole toxicity

2. Thrombocytopenia – R/O real vs. effect of blood clotting

 

Short-term prognosis:

Fair

 

P:

1. Keep in Medical
2. Cerenia 0.2 ml SQ q24 x5 days
3. Monitor for worsening or progression of signs. Otitis may worsen, but idiopathic vestib dz, trauma or infarct may lead to static dz and then slow recovery.
4. LRS 100 ml SQ BID
5. Monitor appetite and elims
6. Recheck daily
7. Seek NH placement. Ideally pt would receive a CT/MRI of the skull to get definitive diagnosis.

 

Re-exam: 4/24

Hx: Did not have vestibular signs 4/22 when vaccinated; today pt has vestibular signs during intake exam.

 

S/O:  Vet check for vestibular signs, monitoring condition.

BAR on presentation

Blanket in cage is urine soaked

Food does not appear eaten

No stool passed overnight

No c/s/v/d

Right sided head tilt remains

Rotary nystagmus present OU – PLR, palpebral, menace remain intact

No ataxia, however patient intermittently circles to the right

SNP abdomen, no masses palpated

No pain elicited on neck movement

Good propioception otherwise

 

A:

Neurologic signs – under treatment

 

Cage Exam: 4/25

VET CHECK – MONITOR CONDITION, VESTIBULAR SIGNS

 

BARH. GOOD APPETITE. NORMAL URINE IN LITTER BOX

RIGHT SIDED HEAD TILT

 

A: NEUROLOGIC

 

P: CONTINUE WITH CURRENT TREATMENT AND MONITORING PLAN.  FAIR PROGNISOS

REC NEW HOPE PLACEMENT

 

Observation: 4/26

good appetite seen for soft and dry food

BAR

NOSF

 

Re-exam: 4/27

Hx: Pt had acute vestibular episode on 4/23/15 with right-sided head tilt, circling to right, and rotary nystagmus. On 4/25/15 pt only had a right-sided head tilt. Today pt has urine in litterbox and appears to have eaten some dry food.

 

S: Timid, sits at back of cage, shies away examiner but then leans into my hand for a head and butt scratch, purrs quietly

 

O: QAR-H, BCS 4.5/9, MMs pink and moist, CRT <2 sec

EENT: No discharge OU, AU, nose. One piece of litter stuck in pt’s left nare.

PLNs: Not enlarged.

H/L: NSR, NMA. Purring so difficult to assess breathing sounds.

Abd: Soft, no pain on palpation, no masses palpated. Bladder half-full.

M/S/I: Amb x4. No lesions noted.

UG: Female.

Neuro: Mild right-sided head tilt. No nystagmus even when pt is placed in dorsal recumbency. No circling observed when pt placed on floor and allowed to walk around.

 

A: Idiopathic vestibular episode on 4/23/15; all signs have resolved besides a mild right-sided head tilt which may disappear over time or may remain permanently

 

Short-term prognosis: Excellent

 

P: No treatment needed at this time

 

Observation: 5/05

HAS NOT HAD VC STILL NEUROLOGIC, HEAD TILT AND VESTIBULAR SIGNS STILL PRESENT

 

P:PUT IN FOR VC/ REASSESS, RC EARS, START MEDS

 

Behavior: Average Home

Notes: Frank was bought into the care center by her previous owner no information regarding her behavior was left. We don’t have any behavioral history previous to what we are seeing during the evaluation. At the time of the assessment she was displaying good behavior, did not come to the front of the kennel but interacts with the Assessor, appreciates attention, is easy to handle and tolerates all petting. Frank is displaying behavior appropriate for new or experienced cat parents.

 

Reaction to assessor: does not come to front but looks at you, calm, relaxed and friendly (1)

When spoken quietly: does not come to front but looks at you, calm, relaxed and friendly (1)

Reaction to door cage opening: remains soft and relaxed (1)

Reaction to touch: allows petting and attention (1)

Try picking cat up: tolerant of this type of handling.

 

Placement Determination: Average

 

CAME IN WITH

WILLIE – A1034011

 https://catarchives.urgentpodr.org/willie-a1034011/

RICKY  –  A1034013

TED – A1034014

https://catarchives.urgentpodr.org/ted-a1034014/

PETE – A1034015

https://catarchives.urgentpodr.org/pete-a1034015/ ‎

ALAN – A1034016

DAVID – A1034019

CAROLINE – A1034021

https://catarchives.urgentpodr.org/caroline-a1034021/

LUNITA – A1034128

https://catarchives.urgentpodr.org/lunita-a1034128/

LAWRENCE – A1034127

https://catarchives.urgentpodr.org/lawrence-a1034127/

 

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