BLAKE – A1049523

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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
Weight 74.4

Upon intake,  easy to handle

MEDICAL:

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

PX:  GOOD

P:  CONTINUE CURRENT TREATMENT PLAN

RECHECK LAMENESS/SWELLING + EXTEND RIMADYL AT END OF TX

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