EMERALD – A1109317
Safe - 4-21-2017 Manhattan Rescue: Staten Island Hope Please honor your pledges: www.statenislandhoperescue.org
SAFE 4/21/17 EMERALD has injuries to left eye – possibly from a burn injury – has some trauma – needs rescue!!
EMERALD – A1109317
MALE, WHITE / GRAY, DOMESTIC SH MIX,2 yrs
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition INJ MINOR Intake Date 04/19/2017, From NY 10458, DueOut Date 04/22/2017,
Medical Behavior Evaluation GREEN
Medical Summary DVM Intake Exam Estimated age: 2-3 Microchip noted on Intake? n History : stray Subjective: low suspect ringworm–woods neg Observed Behavior – solicits petting and rubbing, very socialable Evidence of Cruelty seen – possible but inconclusive Evidence of Trauma seen – yes Objective P = 120 R = wnl BCS 5/9 EENT:OD ulcerative lesion–skin around eye is bald so possible burn injury to area. bleharospasm Oral Exam: clen teeth PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated. pot belly U/G: 2 testes MSI: Ambulatory x 4, skin free of parasites, no masses noted, coat is alopecia on all four legs and left side of head. woods neg. ratty dirty coat CNS: mentation appropriate – no signs of neurologic abnormalities Assessment: injury to left eye, possible healing injuries from burn Plan: terramycin os bid x 10d, DTM, Prognosis: good SURGERY: Okay for surgery /nh placement
Medical Summary 04/20/17 11:32 S: purring and head rubbing during exam, loves belly rubs, eating well O: 5% dehydrated EENT: no discharge AU or nares, no dischanrge OU, deep corneal ulceration with neovascularization OS Oral: no dental tartar, crown fx 304, missing 204, no oral ulcers Int: multiple areas of alopecia on limbs and head (as noted on intake), approx 2cm diameter superficial wound on medial R hock Lnn: WNL CV: NMA, s&s pulses, pink moist mm Resp: clear lungs, eupnic Abd: SNP UG: intact male MS: 4x ambulatory, BCS 3/9 Neuro: BAR, no obvious neuro deficits, complete neuro exam not performed A: deep cornea ulcer wounds alopecia P: cwct obtain serum for OS ulcer treatment px: good, if corneal ulceration does not resolve recommend enucleation
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