CLINTON – A1114650

Manhattan Center

CLINTON – A1114650
NEUTERED MALE, ORG TABBY, DOMESTIC SH MIX,12 yrs
OWNER SUR – EVALUATE, HOLD RELEASED Reason OWNER SICK
Intake condition EXAM REQ Intake Date 06/16/2017, From NY 10024, DueOut Date 06/16/2017,
Medical Behavior Evaluation ORANGE
Medical Summary DVM Intake Exam Estimated age: 12yrs old Microchip noted on Intake? yes 0A100B1453 History : o surrender because o had health problems of her own, was originally adopted from ASPCA Subjective: meowing in carrier, urinated on self prior to exam Observed Behavior – started to growl and swat soon after taking out of carrier Evidence of Cruelty seen – no Evidence of Trauma seen – no Objective VERY LIMITED EXAM D/T TEMPERMENT unable to get RR or HR EENT: Eyes clear, ears clean, no nasal discharge noted Oral Exam: unable to perform PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic, hissing and growling ABD: Very quick palpation-Non painful, no masses palpated U/G: unable to visualize stated to be neutered male MSI: Ambulatory x 4, no masses noted, healthy hair coat, long nails CNS: mentation appropriate – no signs of neurologic abnormalities Assessment obese long nails Plan can attempt another more thorough exam in three days if p has calmed and adjusted at that time; if not, can consider trazadone 25mg PO SID if p will allow oral medication long term rec weight loss of approx 6# over 14months Prognosis: open, pending thorough exam if possible SURGERY: n/a
Weight 21.0

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