OSO – A1119620

OSO – A1119620

**SEIZURE HX**

MALE, TAN, GOLDEN RETR MIX, 5 mos
OWNER SUR – EVALUATE, NO HOLD Reason PET HEALTH
Intake condition EXAM REQ Intake Date 07/24/2017, From NY 10459, DueOut Date 07/24/2017,

Medical Behavior Evaluation GREEN
Medical Summary DVM Intake Exam Estimated age: older puppy, 6-7 mon Microchip noted on Intake? scan negative History : owner surrender with history of seizures and diarrhea diagnosed at rDVM 7/20, discharged 7/22 with Levetiracetum 500mg PO BID and “Proviable” digestive paste to give twice daily; owner’s having trouble giving medication **also reported to have seizures during Bronx intake Subjective: Quiet, slightly depressed, hydrated Observed Behavior – quiet, a little dull, allowed PE Evidence of Cruelty seen – no Evidence of Trauma seen – no Objective T = 102.8 P = 96 R = 40 BCS 4/9 EENT: Eyes clear, ears clean, slight clear nasal discharge noted Oral Exam: nsf PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated; watery diarrhea duing intake U/G: intact male MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat CNS: slightly dull mentation, had two focal/facial seziures – chewing with hypersalivation – which resolved after 20-30 sec Rectal: not performed Assessment: – seizures – uncontrolled – watery diarrhea – elevated temp. Plan – seizure watch overnight and recheck in AM – force fed 500 mg Levetiracetam 500 mg during PE and gave Midazolam (5 mg/mL) 0.4 mL IM – cont. 500 mg Levetiracetem BID – start metronidazole 250 mg PO BID x 5 days Prognosis: open – guarded if unable to control seizures SURGERY: Temporary waiver due to health
Weight 44.0

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