CASEY – 9545
Safe - 10-16-2017 Brooklyn
SAFE 10/16/17 Casey was found as a stray and brought in because he appeared to have trouble breathing. He will need follow up care for his URI, dental disease, and ear infection. He’s allowed all handling and has been quite friendly despite his current medical condition.
Brooklyn Center
Casey 9545, 5 Years Old, White and Black DSH, Neutered, 10 lbs, Stray 10/12/17
Medical:
10/12/17:
Estimated age: 5 year
Microchip noted on Intake? no
History : stray
Subjective: BAR, hydrated
Observed Behavior – Friendly, easily examined and treated with minimal restraint
Evidence of Cruelty seen -no
Evidence of Trauma seen -no
Objective
P =120
R = wnl
BCS: 5/9
EENT: Eyes clear, otitis AU, polyp on right, crusty exudate on left, mild nasal discharge but no ocular discharge noted
Oral Exam: grade 3 periodontal disease
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G: male castrate
MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat
CNS: Mentation appropriate – no signs of neurologic abnormalities
Assessment:
1. URI / sneezing
2. Periodontal disease
3. otitis au, left worse than right
Prognosis: good with appropriate treatment
Plan:
clean ears
move to iso
start doxycycline PO
start otobiotic
recommend periodontal therapy at some point.
continue to monitor at ACC
SURGERY: already altered
Location: Brooklyn
Intake Date: 10/12/17
Intake Type: Stray
Medical Behavior: Green
Sex: Neutered
Age: 4 years
[DVM Intake]
DVM Intake Exam
DVM: 1431
Estimated age: 5 year
Microchip noted on Intake? no
History : stray
Subjective: BAR, hydrated
Observed Behavior – Friendly, easily examined and treated with minimal restraint
Evidence of Cruelty seen -no
Evidence of Trauma seen -no
Objective
P =120
R = wnl
BCS: 5/9
EENT: Eyes clear, otitis AU, polyp on right, crusty exudate on left, mild nasal discharge but no ocular discharge noted
Oral Exam: grade 3 periodontal disease
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G: male castrate
MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat
CNS: Mentation appropriate – no signs of neurologic abnormalities
Assessment:
1. URI / sneezing
2. Periodontal disease
3. otitis au, left worse than right
Prognosis: good with appropriate treatment
Plan:
clean ears
move to iso
start doxycycline PO
start otobiotic
recommend periodontal therapy at some point.
continue to monitor at ACC
SURGERY: already altered
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View all entries in: SAFE Cats 2017-10