MONKEY – A1109621
Safe - 4-27-2017 Brooklyn
MONKEY – A1109621
**DISLOCATED HIP – WILL REQUIRE SURGERY TO CORRECT**
SPAYED FEMALE, WHITE / BLACK, SHIH TZU / MALTESE, 10 yrs
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition INJ MINOR Intake Date 04/22/2017, From NY 11385, DueOut Date 04/25/2017,
Medical Behavior Evaluation GREEN
Medical Summary DVM Intake Exam Spayed female Estimated age: 10 years old Microchip noted on Intake? Negative History : The patient is stable. Limping from the right hind limb. Non weight bearing lameness. Stray dog and friendly with people. Subjective: Geriatric female spatyed dog with heart murmur and right hind limb patellar luxation. Observed Behavior – Friendly with people. Allow restraining. T =Not taken P = 140 bpm R = painting BCS 5/9 Euhydrated EENT: Eyes clear ( tear staining), ears clean, no nasal discharge noted Oral Exam: Periodontal disease PLN: No enlargements noted H/L: Grade 2 cardiac murmur,CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: Spayed female MSI: Non weigh bearing rin on the right hind limb, patellar luxation/painful , skin free of parasites, no masses noted, healthy hair coat CNS: mentation appropriate – no signs of neurologic abnormalities Rectal: not performed Assessment Grade 2 cardiac murmur Periodontal disease Grade 2 cardiac murmur Patellar luxation Painful right hind limb Plan VAccinated Microchipped Dewormed Activyl applied HW negative 0.3 ml rimadyl sq once 12.5 mg rimadyl PO SID with food for 7 days Radiographs of right hind limb.
04/23/17: Recheck right hind lameness, radiographs. S/O: BARH. mm=pink, moist, CRT<2 s. ORAL: Mod to severe caluclus. EENT: No oculonasal discharge, no sneezing. H/L: HR=90, RR=20. Lungs clear. No murmur ausculted this afternnoon. ABD: Soft, non-painful, no masses/organomegaly. MS: Amb x 3, non weight bearing right hind. Gr. 2/4 MPL right stifle, decreased right hip ROM with swelling palpable dorsally. A: Right MPL, suspect right hip luxation. P: Sedated with Dexdomitor 0.3 ml IM. Radiographs of right hind leg: Right craniodorsal hip luxation. Antisedan 0.3 ml IM administered to reverse sedation. Start Tramadol 50 mg. 0.5 tab PO BID x 7 days. Good prognosis with appropriate management – will need surgical treatment (either open reduction of hip joint, or salvage procedure such as FHO).
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