LILLY – A1061559
Urgent 12-30-2015 Brooklyn
LILLY – A1061559
FEMALE, BLACK / WHITE, DOMESTIC SH MIX,3 yrs
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition UNSPECIFIE Intake Date 12/27/2015, From NY 11233, DueOut Date 12/30/2015,
Medical Behavior Evaluation GREEN
Medical Summary Microchip: Negative Sex: Female Age 3 yrs BARH In Right hock joint feels pain Eyes: Clear / wnl Ears: Ear mites, cleaned with ear cleansing soln. Used Ivermectin SQ- 0.08 ml by 1154 Nose: Clear / wnl Teeth: Mild dental staining BCS: 3 Skin: APH / WNL Hair Coat: WNL Any injuries: Mild pain on Rt. hock joint Behavior: Friendly behavior during exam Medication: None — APH NOSF ADDENDUM: RE-EXAMINED PATIENT FOR LAMENESS GAIT ANALYSIS REVEALED A GRADE 2/5 LHL LAMENESS ON ORTHOPEDIC EXAM, PATIENT DID NOT EXPRESS ANY SPECIFIC PAIN AT ANY JOINT OR ALONG LIMB PALPATION (PATIENT SEEMED OVERALL AGITATED WITH BEING HANDLED) NO ASYMMETRIES PALPATED WHEN BOTH HIND LIMBS COMPARED NO SWELLING OR ABNORMALITIES PALPATED ALONG EITHER LIMB DID OBSERVE THAT PATIENT DOES AMBULATE WITH SLIGHTLY DROPPED HOCKS, HOWEVER SUBTLE. EATING WELL OTHERWISE A: LHL LAMENESS – R/O ACUTE TRAUMA VS. PREVIOUS INJURY VS. OTHER PX: GOOD P: GAVE 0.16 ML MELOXICAM SQ ONCE CONTINUE TO MONITOR WHILE IN BACC – RECHECK IN 3 DAYS TO REASSESS LAMENESS
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