MUNECA – A1106688

MUNECA – A1106688

SPAYED FEMALE, WHITE, POODLE TOY MIX, 12 yrs
OWNER SUR – AVAILABLE, NO HOLD Reason PET HEALTH
Intake condition GERIATRIC Intake Date 03/21/2017, From NY 11367, DueOut Date 03/21/2017,

Medical Behavior Evaluation BLUE
Medical Summary Transfer from Queens shelter, presented for owner requested euthanasia. Per history in memo – dog has not eaten in 3 days, was shaking, screaming, collapsing. Owner was concerned she had a brain problem. Was taken to vet hospital – nothing found, recommended pain medication. No records provided. Calm, a lttle shy, allows all handling.  QARH. mm=pink, moist, CRT<2 s. ORAL: Mod. calculus, gingivitis. EENT: No oculonasal discharge, no sneezing. Ear canals WNL AU. PLN: No enlargements noted. H/L: HR=120, RR=16. Lungs clear. Gr 3/6 left sided systolic murmur. No coughing. ABD: Non painful, no masses/organomegaly palpated. U/G: Female, spay scar found. MS: Amb x 4, no lameness. Gr 2/4 medial patellar luxation left stifle, Gr 1/4 MPL right stifle. Neither is painful on palpation. No pain on cervical or T-l spinal palpation. CNS: Mentation appropriate – no signs of neurologic abnormalities. A: Geriatic dog – 12 yrs. Dental disease. Cardiac murmur – r/o acquired mitral valve disease, no signs of CHF. Medial patellar luxation not clinically a problem. History of possible painful episode, collapse – DDx: IVDD, other spinal disease, CNS disease (seizures, stroke/CVA, other). P: No indication that pet is in distress or has a grave medical condition. No euthanasia will be performed. Schedule for CBC/Chem panel. Offered food – ate readily. Start Tramadol 50 mg 0.25 tab PO BID x 5 days. Monitor in medical for signs of pain or collapse.
Weight 9.6

 

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