CORAL – A1111858
Safe - 5-16-2017 Staten Island
SAFE 5/16/17 CORAL IS 10 YRS OLD – SHE IS POSSIBLY BLIND – SHE NEEDS A FULL VET EVAL.
STATEN ISLAND CENTER
CORAL – A1111858
FEMALE, BRN TABBY / WHITE, DOMESTIC SH MIX,10 yrs
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition GERIATRIC Intake Date 05/12/2017, From NY 10314, DueOut Date 05/15/2017,
Medical Behavior Evaluation YELLOW
Medical Summary DVM Intake Exam Estimated age: Approx 10 years old Microchip noted on Intake? scan negative History : stray cat Subjective: Observed Behavior – hissing Evidence of Cruelty seen – no Evidence of Trauma seen – no Objective BCS 4-5/9 EENT: OU-no abnormalities seen but negative menace response, AU-brown debris; left ear pinna tipped, right ear pinna thickened and deformed; no nasal discharge noted but mild nasal congestion Oral Exam: limited oral exam, no teeth seen PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic ABD: Tense, no masses palpated U/G: FI, no spay scar seen MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat CNS: mentation appropriate – no signs of neurologic abnormalities Assessment possibly blind- R/O ocular disease vs neurologic disease vs other mild nasal congestion- R/O infectious vs inflammatory vs neoplasia vs other missing most, possibly all teeth deformed ear pinna- R/O previous hematoma vs trauma vs other Plan monitor for nasal discharge, sneezing, or worsening congestion Prognosis: guarded SURGERY: Permanent waiver due to geriatric
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