XENA – A1108540
Safe - 4-12-2017 Manhattan
SAFE 4/12/17 Xena has heart murmur and needs to be checked.
XENA – A1108540
SPAYED FEMALE, TORTIE, DOMESTIC SH MIX,2 yrs
STRAY – PRE RTO, HOLD RELEASED Reason OWN EVICT
Intake condition EXAM REQ Intake Date 04/11/2017, From NY 10469, DueOut Date 04/18/2017, I came in with Group/Litter #K17-093676.
Medical Behavior Evaluation No Initial Behavior
Medical Summary DVM Intake Exam Estimated age: 4 years Microchip noted on Intake? none History : brought in as a stray Subjective: BAR Observed Behavior – held ears back intermittently but was easy to handle and restrain; good for examination Evidence of Cruelty seen – none Evidence of Trauma seen – none Objective T = not taken P = WNL R =WNL BCS 5/9 EENT: Eyes clear, ears clean, no nasal discharge noted Oral Exam: mm pk, moist; CRT <2 sec; mild enamel hypoplasia on tip of upper canines; mild tartar on 4th pm’s PLN: No enlargements noted H/L: grade II parasternal murmur, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: female, green tattoo noted on abdomen 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 1. Heart murmur Plan recheck heart murmur rec’d CXR +/- echo to evaluate heart murmur further Prognosis: good SURGERY: spayed
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