BAYLEY – A1126480 

BAYLEY – A1126480

FEMALE, TAN / GRAY, YORKSHIRE TERR MIX, 8 yrs
OWNER SUR – EVALUATE, NO HOLD Reason PET HEALTH
Intake condition EXAM REQ Intake Date 09/24/2017, From NY 10039, DueOut Date 09/24/2017,

Medical Behavior Evaluation GREEN
Medical Summary DVM Intake Exam Estimated age: 5-10 years based on dentition Microchip noted on Intake? Scanned neg History : Not walking for last week. Surrendered by the daughter of the owner – previous owner possibly kicked her in the head Subjective: Alert, looks around, trembling Observed Behavior – Allows all handling, relaxed body, no vocalization Objective BAR-H, MMs pink and moist, BCS 4/9 EENT: Normal fundic exams OU. Eyes clear, ears clean, no nasal discharge noted Oral Exam: Severe tartar, gingival recession, gingivitis. Retained deciduous canines. PLN: No enlargements noted H/L: Resp sinus arrhythmia, NMA, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: Female, no mammary masses, well-developed vulva, no discharge MSI: Non-ambulatory in hind legs. Bilateral severe medial patellar luxation – grade 3/4, severe medial buttressing, some joint effusion, possible CrCL tears. Skin free of parasites, no masses noted, healthy hair coat. CNS: mentation appropriate – no signs of neurologic abnormalities. Good PLRs, wheelbarrows well (walks with front legs when hind legs are lifted), lifts hind legs when the dog is carried over to a table. Rectal: Normal externally Assessment: 1. Severe tartar, retained decid teeth 2. Severe MPLs and secondary arthritis, pain, possible secondary CrCL tears Plan 1. Start Rimadyl – injection of 0.15 ml SQ today, 1/4tab of Rimadyl 25 mg tabs SID x10 days 2. Monitor ability to ambulate, recommend orthopedic evaluation for bilateral knee surgery in the near future 3. Recommend dental cleaning in the near future Prognosis: Fair with stifle treatment; guarded without SURGERY: Temporary waiver due to HL lameness 1088
Weight 4.2

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