MERLOT – A1110023
Safe - 5-27-2017 Manhattan
5/27/17 Merlot has some ear inflammation and also needs some dental attention. Friendly boy 3 yrs old – needs a home!
MERLOT – A1110023
NEUTERED MALE, GRAY TABBY / BLACK, DOMESTIC SH MIX,3 yrs
STRAY – STRAYAVAI, NO HOLD Reason STRAY
Intake condition EXAM REQ Intake Date 04/25/2017, From NY 10030, DueOut Date 04/28/2017,
Medical Behavior Evaluation GREEN
Medical Summary DVM Intake Exam Estimated age: 2-3 Microchip noted on Intake? none History : brought in as a stray Subjective: BAR Observed Behavior – nice boy, easy to handle and examine Evidence of Cruelty seen – none Evidence of Trauma seen – none Objective T = not taken P = WNL R =WNL BCS 5/9 EENT: AU-brown and tan waxy discharge; erythema and mild inflammation of canals with focal mild ulceration Eyes/nose clear Oral Exam: mm pk, moist; CRT <2 sec; mild tartar and gingivitis; slanted tip fracture of upper L canine PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: male intact; 2 normal scrotal testicles MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat CNS: mentation appropriate – no signs of neurologic abnormalities Rectal: not performed Assessment Otitis externa fractured upper canine Plan flush ears, apply tresaderm x 10 days rec’d dental cleaning with poss extraction of fractured canine Prognosis: excellent SURGERY: Okay for surgery
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