SERENITY – A1123988

Brooklyn Center

My name is SERENITY. My Animal ID # is A1123988.
I am a female brown and white am pit bull ter mix. The shelter thinks I am about 4 YEARS old.

I came in the shelter as a STRAY on 09/01/2017 from NY 11236, owner surrender reason stated was STRAY.

AT RISK MEMO
No At Risk Memo

MOST RECENT MEDICAL INFORMATION AND WEIGHT
09/05/2017 Exam Type RE-EXAM – Medical Rating is 5 NC – SEVERE CONDITIONS NOT CONTAGIOUS, Behavior Rating is NONE, Weight 34.0 LBS.

Recheck vaginal prolapse, reduced 9/1; monitor urination S/O: P= wnl R=wnl BCS 2/9 BARH. Good appetite. FS 5/9 in cage. Attention seeking, allows all handling and seeks attention. Urine staining on blanket in cage and postured to urinate but only dribbled small amounts of hematuria EENT: Mild conjunctival erythema, no nasal discharge, pink mm, moderate tartar HL: Grade 2/6 HM PMI left apical, RR, Lungs C&E ABD: Soft, non tender, Unable to palpate urinary bladder MS: Ambulatory x 4 UG: Female, vaginal prolapse remains reduced, moderate swelling/edema around vulva A: Presented with vaginal prolapse, reduced 9/1 Emaciated Grade 2/6 HM P: Continue clavamox 13.75mg PO BID Signed up for AXR, CBC, CHEM, UA tomorrow to assess integrity of bladder Poor prognosis

09/01/2017 PET PROFILE MEMO
09/01/17 14:35 During intake Serenity allowed the counselor to pet collar and take her picture with no problems.

WEB MEMO
No Web Memo

09/05/2017 BEHAVIOR EVALUATION – AVERAGE
Exam Type BEHAVIOR
KNOWN HISTORY: None 9/1/17 Unaltered female, stray Previously lived with: Unknown SAFER ASSESSMENT: 9/5/17 Look: 1. Dog holds gaze with soft eyes, soft body. She allows head to be held loosely in Assessor’s cupped hands. Dog holds gaze for three full seconds. Sensitivity: 1. Dog stands still and accepts the touch, her eyes are averted, and her tail is in neutral position with relaxed body posture. Dog’s mouth is closed for at least a portion of the assessment item. Tag: 1. Dog assumes play position and joins the game. Or dog indicates play with huffing, soft ‘popping’ of the body, etc. Squeeze 1/2: 1. Dog gently pulls back her paw. Toy: 1. Minimal interest in toy, dog smells, then turns away. Summary: Serenity was relaxed, and social towards the assessor. No concerns were seen during her handling assessment. PLAYGROUP: Due to Serenity medical condition, she will not participate in Playgroup. Serenity was surrender as a stray so her past behavior with other dogs is unknown. Serenity should be given adequate time to decompress from the shelter and all introductions with novel dogs should be conducted slowly and under supervision INTAKE BEHAVIOR 9/1/17 During intake Serenity allowed the counselor to pet collar and take her picture with no problems. MEDICAL BEHAVIOR: 9/1/17 During the initial examination allows all handling, attention seeking, voracious appetite. ENERGY LEVEL: We have no history on Serenity so we cannot be certain of her behavior in a home environment. Serenity displayed medium energy and movement throughout assessment. Serenity will need daily mental and physical activity to keep her engaged and exercised. RECOMMENDATIONS: Average (suitable for an adopter with an average amount of dog experience)

GROUP BEHAVIOR EVALUATION 
No Group Behavior Summary

09/01/2017 DVM INTAKE PHYSICAL EXAM
Medical rating was 5 NC – SEVERE CONDITIONS NOT CONTAGIOUS, behavior rating was NONE
DVM Intake Exam 9.1.17 Estimated age: ~6-8yrs, female Microchip noted on Intake? No History : Brought in by NYPD Subjective: Observed Behavior – QARH. Allows all handling, attention seeking, voracious appetite Evidence of Cruelty seen – No Evidence of Trauma seen – No Objective P = WNL R = WNL BCS 2/9 EENT: Eyes clear, mild conjunctivitis OU, ears clean, no nasal discharge noted Oral Exam: Moderate dental staining, pink mm PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: Female, vaginal prolapse, possible bladder entrapment, large amount of dirt/debris on prolapse MSI: Ambulatory x 4, skin free of parasites, no masses noted, dirty hair coat CNS: mentation appropriate – no signs of neurologic abnormalities Assessment: Vaginal prolpase, emaciated Plan: Attempted to clean prolapse with NaCl, dificult to remove all debris. Gave clavamox 250mg PO and rimadyl 75mg PO Prognosis: Poor SURGERY: Temporary waiver due to vaginal prolapse and poor body condition Addendum: Sedated with 0.3 ml telazol IV and 0.4 ml hydromorphone IM. Vaginal prolapse cleaned with dilute betadine and rinsed thoroughly with 0.9% NaCl. Generous lubrication applied to vaginal prolapse before gentle reduction by hand attempted. Reduction of vaginal prolapse accomplished with mild straining. A 20 cc syringe case with lubricant utilzed to further reduce the prolapse. One large cruciate suture placed (nylon) on the dorsal vagina to hold prolapse if any straining in hours/days ahead. Plan: Provided 300ml SQ fluids. 250mg clavamox po bid for 7 days and 75mg rimadyl po q24 for 5 days to be provided for ongoing therapy. Continued monitoring for urination important for immediate days following reduction of prolapse. Cruciate suture to be removed in 5-7 days.

09/05/2017 RE-EXAM (LAST MAJOR EXAM)
Medical rating 5 NC – SEVERE CONDITIONS NOT CONTAGIOUS,
Recheck vaginal prolapse, reduced 9/1; monitor urination S/O: P= wnl R=wnl BCS 2/9 BARH. Good appetite. FS 5/9 in cage. Attention seeking, allows all handling and seeks attention. Urine staining on blanket in cage and postured to urinate but only dribbled small amounts of hematuria EENT: Mild conjunctival erythema, no nasal discharge, pink mm, moderate tartar HL: Grade 2/6 HM PMI left apical, RR, Lungs C&E ABD: Soft, non tender, Unable to palpate urinary bladder MS: Ambulatory x 4 UG: Female, vaginal prolapse remains reduced, moderate swelling/edema around vulva A: Presented with vaginal prolapse, reduced 9/1 Emaciated Grade 2/6 HM P: Continue clavamox 13.75mg PO BID Signed up for AXR, CBC, CHEM, UA tomorrow to assess integrity of bladder Poor prognosis

Generated on Sep 5 2017 6:00PM

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