BLAKE – A1049523
Safe 9-2-2015 Brooklyn
BLAKE – A1049523
***RIGHT FRONT LEG LAMENESS***
MALE, BLACK / WHITE, ROTTWEILER / LABRADOR RETR, 1 yr, 5 mos
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition INJ SEVERE Intake Date 08/28/2015, From NY 11207, DueOut Date 08/31/2015,
Medical Behavior Evaluation GREEN
Medical Summary SCAN NEG ~1.5Y, MALE INTACT BARH. ALLOWS ALL HANDLING. GOOD APPETITE. BCS 4/9 TEETH CLEAN, EYES CLEAR, NO OCULAR OR NASAL DISCHARGE, EARS WNL DIRTY HAIR COAT AMBULATORY X 4 — MILD TO MODERATE RF LIMB LAMENESS, SENSITIVE TO TOUCH GAVE RIMADYL 150MG PO. NEEDS FULL EXAM
Upon intake, easy to handle
8/29: S/O: VET CHECK FOR RF LAMENESS; PATIENT IS VERY BAR ON PRESENTATION; ATTENTION SEEKING, VERY GOOD APPETITE; GRADE II/V RFL LAMENESS – PATIENT IS ABLE TO BEAR WEIGHT ON LEG – LAMENESS APPEARS WORSE ON WALK THAN TROT; ON ORTHOPEDIC ASSESSMENT, PATIENT ALLOWED PALPATION AND NORMAL PROM ON ALL JOINTS/BONES EXCEPT DISTAL TO THE CARPUS; ON DIGIT PROM, PATIENT WAS PAINFUL – CRIED AND MOVED LIMB AWAY; UNABLE TO SPECIFY WHICH DIGIT WAS MOST PAINFUL, HOWEVER NOTED A MODERATE SWELLING OVER THE 2ND METACARPAL BONE.
A: RF PAW PAIN/SWELLING – R/O FRACTURE VS. SOFT TISSUE TRAUMA VS. OTHER
P: CONTINUE CURRENT TREATMENT PLAN
RECHECK LAMENESS/SWELLING + EXTEND RIMADYL AT END OF TX
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