KANE – A1116489
Safe - 7-3-2017 Brooklyn
KANE – A1116489
NEUTERED MALE, TAN, LABRADOR RETR / COCKER SPAN, 9 yrs
OWNER SUR – EVALUATE, NO HOLD Reason NO TIME
Intake condition GERIATRIC Intake Date 06/26/2017, From NY 11234, DueOut Date 06/26/2017,
Medical Behavior Evaluation YELLOW
Medical Summary DVM Intake Exam Estimated age: 9 yo intact male retreiver Microchip noted on Intake? neg History : o surrender – no time for dog – personal reasons. Health issues – back arthritis, difficulty climbing stairs. Subjective: BARH. Stilted hip gait – arthritic. Alopecia caudal back. Observed Behavior – Nervous. Allowed petting and most of exam cautiously but growling when checking for microchip. No longer wanted to be handled. Checked hips for arthritis – painful, growled and tried to bite.Objective T = P = 120 R = eup/ pant BCS= 5/9 EENT: Eyes clear, ears clean, no nasal discharge noted Oral Exam: mild- mod tartar and gingivitis PLN: No enlargements noted H/L: NSA, NM, MM pk CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: intact male, 2 scrotal testicles MSI: Ambulatory x 4 but stiff hips. Attempted orthopedic exam – would not allow much manipulation or extension of hips – painful. Skin free of parasites, no masses noted. Thinning hair caudal fourth of back, slightly dry skin. CNS: mentation appropriate – no signs of neurologic abnormalities Rectal: unable to do Assessment: 9 yo intact male Lab Arthritis Alopecia Plan: Routine intake but unable to do HWT and microchip. Do tomorrow after couple doses pain meds. Rimadyl 75 mg 1 po bid x 2 day trial. Re-check after – rectal (check prostate) and ortho exam. Rimadyl BID or SID after? Prognosis: Fair SURGERY: Permanent waiver due to geriatric age.
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