JAMES – A1108543
Urgent - Brooklyn
5 yr old tuxie girl has a wound which needs vet assessment to determine if something more serious or just a superficial wound.
JAMES – A1108543
FEMALE, GRAY / WHITE, DOMESTIC SH,5 yrs
SEIZED – ONHOLDHERE, NO HOLD Reason LLORDPRIVA
Intake condition ILLNESS Intake Date 04/11/2017, From NY 11226, DueOut Date ,
Medical Behavior Evaluation GREEN
Medical Summary DVM Intake Exam 04/11/17 Estimated age: ~5yrs, female Microchip noted on Intake? No History : Seized, confidential Subjective: Observed Behavior – Q/BARH, allows all handling, purring through exam Evidence of Cruelty seen – No Evidence of Trauma seen – Possible Objective P = wnl, purring R = wnl BCS 4/9 EENT: Eyes clear, ears clean, no nasal discharge noted Oral Exam: Teeth clean, pink mm PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G:Female, no spay scar seen MSI: Ambulatory x 4, skin free of parasites, no masses noted, Superficial wounds/abrasions with thin film of purulent discharge lateral to right cranial mammary gland, at right axillary region and right stifle, no underlying masses at or around mammary gland CNS: mentation appropriate – no signs of neurologic abnormalities Assessment: Wounds, difficult to determine if wounds at axillary region and stifle are due to rubbing from primary wound near mammary gland — (may be early signs of mammary gland tumor vs other) Plan: Gave convenia 0.3ml SQ. Rec cleaning with nolvasan q24 x 3 days Prognosis: Good if only superficial wound SURGERY: Okay for surgery
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