STORMZY – A1112910
Safe - 5-25-2017 Manhattan
SAFE 5/25/17 Super sweet and loves to be petted! 10 year old Stormzy was dumped along with housemate for pet health. She is a spayed girl with cataracts, and a history of intestinal issues, has anal gland inflammation, and needs some dental care. She needs a full vet eval.
STORMZY – A1112910
SPAYED FEMALE, BRN TABBY, PERSIAN MIX,10 yrs
OWNER SUR – AVAILABLE, NO HOLD Reason PET HEALTH
Intake condition EXAM REQ Intake Date 05/23/2017, From NY 10463, DueOut Date 05/23/2017, I came in with Group/Litter #K17-098182.
Medical Behavior Evaluation GREEN
Medical Summary DVM Intake Exam Estimated age: Microchip noted on Intake? History : owner surrender; owner reports that storm has a mass and has been bleeding from rectum for about a year Subjective: BAR Observed Behavior – very sweet! loves being pet; allows handling Evidence of Cruelty seen – none Evidence of Trauma seen – none Objective BCS 5/9 EENT: OD- iris defect ventrally with pigmentation in anterior chamber; immature cataract; no active process-suspect old trauma Oral Exam: mm pk, moist; CRT <2 sec; mod tartar; tip fracture of upper canines PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: soft, nonpainful with no palpable abnormalities; rectum appears WNL U/G: female spayed MSI: ambulatory x 4 with no signs of orthopedic disease; matt in fur on abdomen and on tail; no palpable masses but matt CNS: mentation appropriate – no signs of neurologic abnormalities Rectal: no apparent abnormalities; lgt brown fecal staining on glove Assessment 1. Cataracts/iris defect-suspect old trauma with residual chronic changes in eye 2. fractured canines 3. h/o rectal bleeding-r/o chronic colitis (IBD vs lymphoma vs parasites) vs anal gland inflammation vs other Plan Rec’d dental cleaning with poss extractions Monitor for signs of sysetmic dz-if any concerns, then rec’d CBC/chem/T4 Monitor for diarrhea/rectal hemorrhage Ideally rec’d ophtho consult, at minimum rec’d monitoring IOP every 6-8 months Prognosis: good to excellent; suspect changes to eye are from previous injury and do not seem to be affecting vision; cataract in that eye may eventually progress but do not suspect it will have significant impact on quality of life, although there may be increased risk of glaucoma in that eye; no mass was noted today on exam-suspect that matt on abdomen could have been mistaken for mass SURGE
Came in With
View all entries in: Safe Cats 2017-05