SAFE – 04/07/15 PEBBLES – A1032278 – MANHATTAN, NY
Safe 4-7-2015 Manhattan
SAFE – 04/07/15
SAFE – 04/07/15
Manhattan Center
My name is PEBBLES. My Animal ID # is A1032278.
Pulled by Louie’s Legacy Animal Rescue
Please honor your pledges: www.louieslegacy.org (click paypal link)
I am a spayed female gray and white shih tzu. The shelter thinks I am about 5 YEARS old.
I came in the shelter as a OWNER SUR on 04/05/2015 from NY 10453, owner surrender reason stated was COST.
MOST RECENT MEDICAL INFORMATION AND WEIGHT
04/06/2015 Exam Type RE-EXAM – Medical Rating is 4 NC – SEVERE CONDITIONS NOT CONTAGIOUS, Medical Behavior Evaluation GREEN , Weight 18.2 LBS.
4/6 non weight bearing lame RF leg seems painful, but hard to tell–cries when touched anywhere on body tense abdomem small mgts on abdomen gave 0.3ml (5mg/ml) meloxicam sq Scan negative S/O: quiet when unattended, whining when interacted with Appearance: QAR, hydrated Integument: intact hair coat, normal nails EENT: OU clear, AU clean, No nasal d/c Oral cavity: MM pink, CRT <2sec, Healthy dentition with minimal calculus PLN: WNL H/L: No murmur or arrhythmias, Lungs clear ABD: tense and mildly distended, whines when palpated but generally whines when touched, no obvious masses or organomegaly but deep palpation limited by abdominal tension and distention U/G: female spayed, mammary tumors on left caufal mammary chain M/S: Amb x 3, non-weight bearing lame on right forelimb (dragging paw), thiuckening palpable in area of mid-radius/ulna (+/- callus from prior fracture), no pain on manipulation of joints of forelimb, mild generalized muscle wasting of both hind limbs Neuro: absent CP right forelimb, slow CP on both hind limbs, mild pain on thoracolumbar palaption, resents manipulation of neck to the right A: Right forelimb lameness- r/o brachial plexux avulsion vs. cervical spinal lesion vs. poorly healing fracture vs. other mammary tumor- r/o benign vs. neoplastic P: Tramadol 25 mg PO Q12 RECOMMEND IMMDIATE NH PLACEMENT FOR FURTHER GERIATRIC WORK UP VS. EHR
04/05/2015 PET PROFILE MEMO
04/05/15 17:55 Pebbles’ owner got her from her previous owner. He surrendered her because he can’t afford vet care. She was spayed and vaccinated in the summer of 2014. The vet noted bloody urine and mammary tumors but these issues were never seen/treated. She’s been crying often and dragging her front right leg for 1 month. Pebbles’ owner reports that she’s friendly with all people including strangers and children and has never bit anyone. She’s spent time with small and large dogs and is friendly with all of them. She’s house trained and doesn’t have accidents inside. Pebbles lied on the floor during most of intake. She had soft body and wagged her tail when I approached, talked to, and pet her. She had difficulty walking, dragging her front right leg. She maintained soft body during handling-scanning (negative), collaring, picking up, holding/carrying, and putting her in a kennel. She wagged her tail when I approached/passed her kennel.
WEB MEMO
No Web Memo
BEHAVIOR EVALUATION
No Behavior Summary
GROUP BEHAVIOR EVALUATION
No Group Behavior Summary
04/05/2015 INITIAL PHYSICAL EXAM
Medical rating was 4 NC – SEVERE CONDITIONS NOT CONTAGIOUS, behavior rating was NONE
Scan negative S/O: quiet when unattended, whining when interacted with Appearance: QAR, hydrated Integument: intact hair coat, normal nails EENT: OU clear, AU clean, No nasal d/c Oral cavity: MM pink, CRT <2sec, Healthy dentition with minimal calculus PLN: WNL H/L: No murmur or arrhythmias, Lungs clear ABD: tense and mildly distended, whines when palpated but generally whines when touched, no obvious masses or organomegaly but deep palpation limited by abdominal tension and distention U/G: female spayed, mammary tumors on left caufal mammary chain M/S: Amb x 3, non-weight bearing lame on right forelimb (dragging paw), thiuckening palpable in area of mid-radius/ulna (+/- callus from prior fracture), no pain on manipulation of joints of forelimb, mild generalized muscle wasting of both hind limbs Neuro: absent CP right forelimb, slow CP on both hind limbs, mild pain on thoracolumbar palaption, resents manipulation of neck to the right A: Right forelimb lameness- r/o brachial plexux avulsion vs. cervical spinal lesion vs. poorly healing fracture vs. other mammary tumor- r/o benign vs. neoplastic P: Tramadol 25 mg PO Q12 RECOMMEND IMMDIATE NH PLACEMENT FOR FURTHER GERIATRIC WORK UP VS. EHR
04/06/2015 RE-EXAM (LAST MAJOR EXAM)
Medical rating 4 NC – SEVERE CONDITIONS NOT CONTAGIOUS,
4/6 non weight bearing lame RF leg seems painful, but hard to tell–cries when touched anywhere on body tense abdomem small mgts on abdomen gave 0.3ml (5mg/ml) meloxicam sq Scan negative S/O: quiet when unattended, whining when interacted with Appearance: QAR, hydrated Integument: intact hair coat, normal nails EENT: OU clear, AU clean, No nasal d/c Oral cavity: MM pink, CRT <2sec, Healthy dentition with minimal calculus PLN: WNL H/L: No murmur or arrhythmias, Lungs clear ABD: tense and mildly distended, whines when palpated but generally whines when touched, no obvious masses or organomegaly but deep palpation limited by abdominal tension and distention U/G: female spayed, mammary tumors on left caufal mammary chain M/S: Amb x 3, non-weight bearing lame on right forelimb (dragging paw), thiuckening palpable in area of mid-radius/ulna (+/- callus from prior fracture), no pain on manipulation of joints of forelimb, mild generalized muscle wasting of both hind limbs Neuro: absent CP right forelimb, slow CP on both hind limbs, mild pain on thoracolumbar palaption, resents manipulation of neck to the right A: Right forelimb lameness- r/o brachial plexux avulsion vs. cervical spinal lesion vs. poorly healing fracture vs. other mammary tumor- r/o benign vs. neoplastic P: Tramadol 25 mg PO Q12 RECOMMEND IMMDIATE NH PLACEMENT FOR FURTHER GERIATRIC WORK UP VS. EHR
Meet Pebbles!! This little lady came in with a mammary tumor, and is not bearing weight on her front right leg. It appears as though she may have had a fracture which is healing poorly, but she will need a full medical work up to determine the extent of her injury or if it is possible nerve damage.
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