YOYO – A1109488
Safe - 4-28-2017 Brooklyn
SAFE 4/28/17 FRIENDLY, PURRING YOYO HAS AN EYE ISSUE AND NEEDS FOLLOW UP VET CARE TO DETERMINE CAUSE – ALREADY SPAYED AND READY TO GO!
YOYO – A1109488
SPAYED FEMALE, WHITE / TORTIE, DOMESTIC SH MIX,3 yrs
STRAY – ONHOLDAVAI, HOLD FOR ID Reason STRAY
Intake condition EXAM REQ Intake Date 04/20/2017, From NY 10456, DueOut Date 04/28/2017,
Medical Behavior Evaluation GREEN
Medical Summary DVM Intake Exam Estimated age: 2-4 years based on overall condition and dentition Microchip noted on Intake? Scanned positive – MC#985112007465675 History : Stray Subjective: Alert, obese, apparently healthy Observed Behavior – Purring, allows petting, puts hind end up in response to butt scratches. Minimal restraint needed for vaccines and ear cleaning. Objective BCS 8/9, MMs pink and moist EENT: OD moderate epiphora, small oval region of corneal opacity. No neovascularization or chemosis. OS WNL. Moderate black granular discharge AU, pinnal-pedal reflex. No nasal discharge noted. Oral Exam: Clean teeth. PLN: No enlargements noted H/L: Purring. NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Large, lumpy. Non painful on palpation, soft. U/G: Female, appears to be spayed MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat CNS: Mentation appropriate – no signs of neurologic abnormalities Assessment: 1. Obese 2. Likely ear mites 3. OD irritation and corneal opacity – R/O corneal ulcer vs. other Plan 1. Cleaned ears during exam, clean every 3-4 days; apply Tresaderm AU BID x10 days 2. Recommend weight loss of 3-5 lbs 3. Fluorescein stain and ophthalmoscopic exam once pt reaches MACC Prognosis: Good 1088
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