WINSTON – A1054095
Safe - 6-5-2017 Manhattan
SAFE 6/5/17 Winston is a return to the shelter – he has some ear issues but is otherwise healthy – neutered and ready to go!
WINSTON – A1054095
NEUTERED MALE, ORG TABBY, DOMESTIC SH MIX,3 yrs
STRAY – ONHOLDAVAI, HOLD FOR ID Reason STRAY
Intake condition EXAM REQ Intake Date 05/30/2017, From NY 10029, DueOut Date 06/02/2017,
Medical Behavior Evaluation GREEN
Medical Summary DVM Intake Exam Estimated age: Microchip noted on Intake? History : stray, from ACC Subjective: previous heard HM not apparent today Observed Behavior – intitally head butting but became irritated after ears cleaned. still allowed exam Evidence of Cruelty seen – n Evidence of Trauma seen – n Objective P = 120 R = wnl BCS 5/9 EENT: AU pruritis and balck waxy d/c Oral Exam: clean teeth PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: neutered MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat CNS: mentation appropriate – no signs of neurologic abnormalities Assessment: otitis externa Plan: tresaderm au bid x 10d Prognosis: good
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