Jeffrey
Monday, August 4, 2025 at 12:39 PM
Subjective
Chief Complaint
Mary brought her dog, Jeffrey, in for an evaluation due to concerns about stumbling and changes in mobility.
History
- Stumbling and unsteady gait have been present for approximately one week.
- Episodes occur primarily during walking; Jeffrey occasionally falls or struggles with balance.
- Difficulty rising from a lying position; requires extra effort to stand.
- No changes in appetite, water intake, urination, or defecation.
- No vocalizing or overt signs of pain, but mild sensitivity when hind limbs are touched.
- Still interested in walks but tires more quickly than usual.
- No history of trauma or toxin exposure.
Objective
Cranial Nerves
- Olfactory (CN I): Normal on exam
- Menace Response (CN II & VII): Present bilaterally
- Optic (CN II): Pupils responsive to light
- PLR Direct: Present and brisk
- PLR Consensual: Present
- Palpebral Reflex (CN V & VII): Normal bilaterally
- Facial Symmetry (CN VII): Symmetrical
- Jaw Tone/Temporalis (CN V): Normal strength and muscle tone
- Oculocephalic Reflex (CN III, IV, VI, VIII): Normal
- Strabismus: Not present
- Nystagmus: Not observed
- Gag Reflex (CN IX & X): Present
- Spinal Accessory (CN XI): Normal range of motion
- Tongue (CN XII): Midline and normal tone
Postural Reactions
- Proprioception: Normal in all four limbs
- Hopping: Appropriate response in all limbs
- Wheelbarrow Test: Normal posture and coordination
- Hemiwalking: Symmetrical and responsive
- Visual Placing: Normal
- Tactile Placing: Normal
- Stairs: Navigated with slight hesitation, but able to perform
- Extensor Postural Thrust: Normal
Spinal Reflexes
- Biceps (C6–C8): Normal
- Triceps (C7–T1): Normal
- Patellar (L4–L6): Normal
- Gastrocnemius (L7–S1): Normal
- Cranial Tibial: Normal
- Crossed Extensor: Not present (normal in recumbent dog)
- Cutaneous Trunci: Present bilaterally; normal reflex arc
Lumbosacral Reflexes
- Anal Tone/Perineal Sensation: Intact
- Tail Tone: Normal
Palpation
- Cervical Spine: No pain or rigidity
- Thoracic Spine: No discomfort
- Lumbar Spine: No pain or tension
- Sacral Spine: Normal
- Musculature: Normal tone; no atrophy or asymmetry
- Hyperesthesia: Not elicited on spinal palpation
Assessment
Overall Assessment
Jeffrey presents with a history of recent-onset
ataxia without localizing neurological deficits. No cranial nerve abnormalities or spinal pain were identified. His proprioceptive responses are intact, suggesting this may be a
cerebellar or central vestibular syndrome, though a
thoracolumbar lesion cannot be fully ruled out without imaging.
Potential differentials include:
- Degenerative myelopathy
- Intervertebral disc disease (IVDD) (less likely due to normal spinal palpation and reflexes)
- Early neoplasia affecting spinal cord or brainstem
- Inflammatory/infectious CNS disease
- Metabolic or toxin-related neuropathy (less likely due to absence of systemic signs)
Plan
Diagnostics
- Blood panel submitted today (CBC, Chemistry, Electrolytes) to screen for systemic illness, metabolic abnormalities, or infectious disease indicators.
- Urinalysis pending.
- Infectious disease titers (e.g., distemper, tick-borne diseases) may be considered pending blood work.
Imaging
- Advanced imaging (MRI or CT) recommended if blood work is unremarkable, to assess for intracranial or spinal pathology.
- Cervical and thoracolumbar spine imaging will help rule out compressive lesions or neoplasia.
Owner Communication
- Mary was advised to observe closely for worsening mobility, acute collapse, circling, or seizure activity.
- We discussed that if symptoms progress rapidly or Jeffrey becomes non-ambulatory, hospitalization may be required.
- A follow-up visit is scheduled in 5–7 days to review lab results and determine next diagnostic steps.
Client Discharge Note
Thank you for bringing Jeffrey in today. It was a pleasure to meet with you both, and we appreciate your attentiveness to his health.
Summary
During today's visit, we discussed Jeffrey's recent symptoms, including stumbling, wobbliness, and difficulty with his back legs. A neurological examination was performed, which revealed delayed reflexes and signs of ataxia. Ataxia can result from various underlying conditions, and further diagnostic tests are necessary to determine the cause.
Key Topics We Discussed
- Blood Work: Blood samples were collected today to check for signs of infection, inflammation, or metabolic issues. Results are expected within a few hours, and we will contact you to discuss them.
- Monitoring at Home: Please observe Jeffrey closely for any sudden changes, such as severe lethargy, inability to stand, or seizures. If any of these occur, contact us immediately.
- Daily Routine: Maintain as much normalcy as possible in Jeffrey's routine, but keep walks shorter to accommodate his reduced energy levels.
- Follow-Up Appointment: A follow-up visit will be scheduled to review the blood work results and discuss the next steps, which may include imaging studies like an MRI or CT scan if necessary.
Thank you for entrusting us with Jeffrey's care! Please do not hesitate to contact us if you have any questions or concerns.
— Dr. Sasha Martinez, DVM, DACVIM (Neurology)