GINA – A1048473

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Brooklyn Center 

My name is GINA. My Animal ID # is A1048473.
I am a spayed female chocolate labrador retr. The shelter thinks I am about 14 YEARS old.

I came in the shelter as a STRAY on 08/19/2015 from NY 11361, owner surrender reason stated was STRAY.

MOST RECENT MEDICAL INFORMATION AND WEIGHT
08/20/2015 Exam Type VACCINATE – Medical Rating is 3 NC – MAJOR CONDITIONS NOT CONTAGIOUS, Behavior Rating is NONE, Weight 58.4 LBS.

4mL Activyl aplied 6mL Pyrantel given

08/19/2015 PET PROFILE MEMO
8/19/15 Was able to put leash on dog and walk slowy.

WEB MEMO
No Web Memo

BEHAVIOR EVALUATION 
No Behavior Summary

GROUP BEHAVIOR EVALUATION 
No Group Behavior Summary

08/20/2015 INITIAL PHYSICAL EXAM
Medical rating was 4 NC – SEVERE CONDITIONS NOT CONTAGIOUS, behavior rating was NONE
Scanned negative QARH – patient, allows handling S~14 years Ears dirty/warts – cleaned with Otic solution and applied Otomax Grade IV/VI heart murmur – PMI on left side, systolic Eyes cloudy Rotary nystagmus present OU Nose clear Mouth – receding gums, gingivitis and tarter appropriate to age Head tilted to right Hips stiff – barely able to walk or support weight on hind legs Crepitus palpable when stifles rotated moderate muscle wasting Nails overgrown – trimmed Skin tag/growth behind right elbow Scabbing behind left elbow A: Nystagmus – r/o secondary to inner ear disease vs. neurologic (old dog vestibular disease) vs. neoplasia vs. other head tilt – see A1 Otitis externa heart murmur cachexia likely arthritic mod. dental disease masses/growth px: fair to guarded P: start course of tramadol for pain – will hold on rimadyl due to age – 75 mg po bid x 7 days schedule ear cleanings with otibiotic – sid x 7 days monitor overall conidition – recommend New Hope placement with full senior profile/lab work done and further neurologic assessment

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