Case 4

Data Base Collection

SIGNALMENT: Canine, mixed breed, f/s, adult

HISTORY: Hit by car 18 hours prior to examination. Dog initially was comatose, but regained consciousness within 12 hours.

PHYSICAL EXAMINATION:	T	99	HR	70	RR	20
	CRT	<3.0secs	MM	Pink	WT	60 lbs.
Examination reveals no injuries other than those related to the neurological examination.

NEUROLOGICAL EXAMINATION:

A. MENTAL STATUS: Depressed. Responds to loud noises. Has trouble localizing noises.

B. POSTURE: Walks in large circles to right. No head tilt is present.

C. PALPATION: Swelling over right frontal area of skull.

D. GAIT: Relatively normal. Slow to start but once moving, the gait is normal.

E. POSTURAL REACTIONS:
(0=absent, +1=decreased, +2=normal, +3=increased/exaggerated, NE=not examined)

LEFT
REACTIONS
RIGHT

Proprioceptive Positioning
PL
TL

0 2

1 2

1 Wheelbarrowing 2

Hopping
PL
TL

1 2

1 2

1 Extensor Postural
Thrust 2

1 Hemistand-Hemiwalk 2

1 Tonic Neck 2

Placing, tactile
PL
TL

0 2

0 2

Placing, visual
PL
TL

0 2

0 2

F. SPINAL REFLEXES:
(0=absent, +1=decreased, +2=normal, +3=increased/exaggerated, +4=clonic, NE=not examined)

LEFT
REFLEX, SPINAL
SEGMENT

RIGHT

3
Quadriceps
(L4-L6)
2

2
Flexion, PL
(L5-S1)
2

2
Flexion, TL
(C6-T1)
2

2
Triceps
(C7-T1)
2

0
Crossed
Extensor
0

2
Perineal
(S1-S2)
2

G. CRANIAL NERVES:
(0=absent, +1=decreased, +2=normal, +3=increased/exaggerated, NE=not examined)

LEFT
(Response/Test)
RIGHT

0
Menace
(CN II & VII)
2

1
Palpebral
(CN V & VII)
2

2 Pupil Size 2

PLR’S
Stimulate left eye
Stimulate right eye
(CN II & III)

2 2

2 2

0 Strabismus 0

0 Nystagmus 0

1
Facial Sensation
(CN V)
2

2
Mastication
(CN V)
2

2
Swallowing/Gag
(CN IX & X)
2

2
Tongue
(CN XII)
2

H. SENSATION:
(0=absent, +1=decreased, +2=normal, +3=increased/exaggerated, NE=not examined)

Location
left limbs

Hyperesthesia
not present

Superficial pain
+1

Deep pain
+2

Assessment of Neurological Findings

ANATOMIC DIAGNOSIS:
(Choose those that apply to the findings in this case):

Generalized LMN

Peripheral nerve

Spinal Cord C1-C5

Spinal Cord C6-T2

Spinal Cord T3-L3

Spinal Cord L4-S3

Cauda equina

Peripheral vestibular

Central vestibular

Brainstem

Cerebral cortex

Cerebellum

Cranial neuropathy

Myopathy

Musculoskeletal
Expert's Anatomic Diagnosis

LESION LOCATION: Where is the lesion located?
	Right
	Left
	Bilateral
	Expert's Lesion Location
REVIEW RADIOGRAPHS:
	Lumbosacral:
	Thoracolumbar:
	Cervical:
	Skull:
	Appendicular
WHICH SET ILLUSTRATES THIS CASE?

LEFT	REFLEX, SPINAL SEGMENT	RIGHT
3	Quadriceps (L4-L6)	2
2	Flexion, PL (L5-S1)	2
2	Flexion, TL (C6-T1)	2
2	Triceps (C7-T1)	2
0	Crossed Extensor	0
2	Perineal (S1-S2)	2

LEFT	(Response/Test)	RIGHT
0	Menace (CN II & VII)	2
1	Palpebral (CN V & VII)	2
2	Pupil Size	2
	PLR’S Stimulate left eye Stimulate right eye (CN II & III)
2		2
2		2

0	Strabismus	0
0	Nystagmus	0
1	Facial Sensation (CN V)	2
2	Mastication (CN V)	2
2	Swallowing/Gag (CN IX & X)	2
2	Tongue (CN XII)	2

Lumbosacral, Set A	Lumbosacral, Set B	Thoracolumbar, Set C
Thoracolumbar, Set D	Cervical, Set E	Cervical, Set F
Skull, Set G	Skull, Set H	Appendicular, Set I
Appendicular, Set J	Expert's Explanation

LEFT	REACTIONS	RIGHT
	Proprioceptive Positioning PL TL
0		2
1		2
1	Wheelbarrowing	2
	Hopping PL TL
1		2
1		2
1	Extensor Postural Thrust	2
1	Hemistand-Hemiwalk	2
1	Tonic Neck	2
	Placing, tactile PL TL
0		2
0		2
	Placing, visual PL TL
0		2
0		2

Location	left limbs
Hyperesthesia	not present
Superficial pain	+1
Deep pain	+2

Generalized LMN		Peripheral nerve
Spinal Cord C1-C5		Spinal Cord C6-T2
Spinal Cord T3-L3		Spinal Cord L4-S3
Cauda equina		Peripheral vestibular
Central vestibular		Brainstem
Cerebral cortex		Cerebellum
Cranial neuropathy		Myopathy
Musculoskeletal	Expert's Anatomic Diagnosis

Data Base Collection

Assessment of Neurological Findings

ANATOMIC DIAGNOSIS: (Choose those that apply to the findings in this case):

ANATOMIC DIAGNOSIS:
(Choose those that apply to the findings in this case):