May 01, 2008 06:03PM
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Physical Exam:
Very Stressed T=104 (usually 101.5-102), P=90bpm, R=? panting, Weight=143.88#, Mucus Memgranes=pink & moist, Cap. Refill Time=<2 seconds.
Ortho Exam:
Slight lameness on L rear when walking and trotting. Mild ataxia (inability to coordinate voluntary muscular movements) when at a walk & trot.
Slight muscle atrophy (wasting) on the L rear let.
Grade l/lV medial patellar luxation on the R rear. (inside side of knee is not alaigned right= slight dislocation
Neuro Exam:
Mild ataxia on the rear.
Cranial Nerves all normal
Left and Right: No abnormalities on forelimbs. Mild hyperreflexia of patellar & canial tibial on rear. (reflexes stronger than they should be on upper part of knee)
Mild hyperpathia at the caudal cervical vertebra when turning head to the left, no other sensory abnormalities noted.
(disagreeable/painfull in response to a normall innocuous stimulus; condition in which hyperpathia occurs.)
MY NOTE: Just think he did not want to comply any more.
Recommendarions & Instructions:
Restrict activity to only leash walks for the next 2 wks. Phone in reports in 2 weeks. Also use a harness instead of a neck collar to walk in case of a cervical lesion. Administer w/ food, Dermamaxx 150 mg (1.5 tabs OD) for the next 2 wks for inflammation. Poss. side effects are: vomiting, diarrhea, & inappetance. If any occur discontinue use and contact Dr. ____ to be switched to another drug.
Prognosis: The difinitive diagnosis is unknown at this point but it likely a mild caudal cervical spondylopathy or Wobblre. This is a type of spinal cord compression that may change with head position and may be from the intervertebral disc or a malformation of the vertebrae. At this point it is very mild and we do not recommend any imaging or sx. Conservative maagement may be sufficient to relieve clinical signs. This may progress over time though and require further diagnostics in the furture.
MY NOTE: We asked about a stomack tack for bloat precaution and they HIGHLY recomend it!
Hopefully around the 1st week of June we can have this done endoscopically with no outside insicion.
All and all pretty good appt. considering.
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