SASHA – A1083810
Safe - 8-7-2016 Manhattan
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SASHA – A1083810
FEMALE, TAN / BLACK, PUG MIX, 8 yrs
STRAY – STRAY WAIT, NO HOLD Reason PET HEALTH
Intake condition EXAM REQ Intake Date 08/02/2016, From NY 10465, DueOut Date 08/02/2016
Medical Behavior Evaluation GREEN
Medical Summary Hx: Finder apparently took pt to vet, who said pt had broken front and back legs. S: Alert, calm, allows all handling O: BAR-H, BCS 5/9, MMs pink and moist EENT: Serous nasal discharge. No discharge OU, AU. Severe tartar and gingivitis. H/L: NSR, NMA. Referred upper resp sounds. Abd: Soft, no pain on palpation, no masses palpated M/S/I: Partially weight-bearing on R front leg and possibly on R hind leg as well. No laxity palpated. Mild swelling at right carpus and L hock. No skin lesions noted. UG: Female Quick DP rads of R front and hind legs – possible fracture at proximal epiphysis of right 2nd metacarpal. No other obvious long bone fractures. A: 1. Lame R front leg – possible fracture of R 2nd metacarpal vs. sprain/strain vs. other 2. Lame R hind leg – R/O undiagnosed fracture vs soft tissue injury 3. Dental disease Short-term prognosis: Fair P: 1. Rimadyl 37.5 mg PO SID x10 days 2. Buprenorphine 0.4 ml SQ BID x5 days 3. Rec orthopedic consult 1088
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