PEACEFUL – A1112766
Safe - 5-24-2017 Manhattan
SAFE 5/24/17 Owner became ill and 11 year old Peaceful was brought to the shelter – she needs follow up vet eval and some dental care.
PEACEFUL – A1112766
FEMALE, RED, ABYSSINIAN MIX,11 yrs
OWNER SUR – EVALUATE, NO HOLD Reason OWNER SICK
Intake condition EXAM REQ Intake Date 05/21/2017, From NY 10029, DueOut Date 05/21/2017,
Medical Behavior Evaluation BLUE
Medical Summary DVM Intake Exam Estimated age: reported to be 11 years old Microchip noted on Intake? History : owner surrender; o says abdomen appears distended but no other health concerns Subjective: QAR Observed Behavior – allows handling Evidence of Cruelty seen – none Evidence of Trauma seen – none Objective BCS 3.5/9 EENT: OU-pupils dilated, iris atrophy AU-brown waxy dishcarge, sl pruritic; comedones and ceruminous gland adenoma Oral Exam: mm pk, moist; CRt <2 sec; tartar build up especially on 4th premolars with gingivitis and focal ulceration PLN: No enlargements noted H/L: mild increase in inspiratory effort; normal lung sounds; no murmur or arrhythmias ABD: soft, nonpainful; sl doughy U/G: female MSI: mild perivulvular irritation; coat sl unthrifty; mild diffuse muscle atrophy CNS: mentation appropriate – no signs of neurologic abnormalities Rectal: not performed Assessment 1. muscle loss 2. increased inspiratory effort-r/o behavioral vs asthma vs other 3. dental disease Plan Rec’d CBC/chem/T4 Rec’d full body rads Monitor for signs of systemic dz Rec’d dental cleaning with poss extractions Prognosis: good to fair SURGERY: temp due to geriatric
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