COOKIE – A1116388

COOKIE – A1116388

**RETURNED 07/06/17**HAS PNEUMONIA**

SPAYED FEMALE, BROWN / WHITE, LABRADOR RETR MIX, 4 yrs
RETURN – PLACED, HOLD RELEASED Reason PET HEALTH
Intake condition ILLNESS Intake Date 07/06/2017, From NY 10466, DueOut Date 07/06/2017

Medical Behavior Evaluation GREEN
Medical Summary Hx: Adopted on 6/29/17, went home with doxycycline for CIRDC. was seen at ACC 2 days ago, nbo indications of pneumonia, adopter is concerned that p is not eating, coughing and vomited 3x in 1hr. Owners decribed “vomiting” to Dr 1301 – consistent with cough with terminal retch, and stated that cookie is letargic and anorexic, has to be carried out to urinate. S: quiet, sweet, alows full exam, intermittent productive cough O: temp 101.3 5-6% dehydrated EENT: mild mucoid nasal dc, no sneezing noted Oral: moderate dental tartar on canines Int: small alceration under chin healing, spay incion has moderate dry hemorrhage with no swelling or active dc Lnn: WNL CV: NMA, s&s pulses, pink moist mm Resp: increased lung sounds, tachypnic RR 80/min, cough with terminal retch Abd: SNP UG: spayed female, no vulvar dc MS: 4x ambulatory, BCS 4/9 Neuro: QAR, no obvious neuro deficits, complete neuro exam not performed A: CIRDC vs pneumonia vs other P: 400ml LRS SQ Thoracic rads: interstitial pattern throughout, suspect air bonchograms in dorsal fields on Lateral, rotated on VD dt difficulty restraining in dorsal, unable to see R lung fields well IVC at 40ml/hr discontinue Doxy contineu clavamox if eating 1.4ml Baytril (100mg/ml) SQ spoike with owners, will start treatment for pneumonia, and transfer to overnight ER today.
Weight 32.0

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ADOPTED 06/29/17

FEMALE, RED / WHITE, AM PIT BULL TER MIX, 4 yrs
STRAY – ONHOLDHERE, HOLD RELEASED Reason NO TIME
Intake condition EXAM REQ Intake Date 06/24/2017, From NY 10466, DueOut Date 06/27/2017

Medical Behavior Evaluation GREEN
Medical Summary  Estimated age: ~4 years Microchip noted on Intake? scan negative. Very hyper, anxious, barks but allows exam  T = P = R = BCS 3/9 EENT: Eyes clear, ears clean, no nasal discharge noted Oral Exam: adult dentition, moderate tartar, worn teeth – looks like she bites on bars — recommend dental after placement PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: female, suspect intact MSI: Ambulatory x 4, slightly underweight (BCS 3/9), wound under chin, broken digit 4 on right front paw – bleeding stopped on exam CNS: mentation appropriate – no signs of neurologic abnormalities Rectal: not performed Assessment ~4 year old female intact dog intact slightly underweight broken toe nail on digit 4 of right front paw laceration under chin dental disease – recommend dental after placement Plan Needs spay – recommend cleaning wounds at time of spay while under sedation Clavamox 250 mg tab: 1 tab PO BID x 10 days Rimadyl 75 mg tab: 1/2 tab PO BID x 5 days Prognosis: Good SURGERY: Okay for surgery
Weight 32.0

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