LUNA – 21386

MANHATTAN CENTER

Luna 21386

Location: Manhattan

Intake Date: 2/22/18

Intake Type: Owner Surrender

Medical Behavior: Blue

Sex: Spayed Female

Age: 1 year

Original Location: 10030

DVM Intake Exam

Estimated age: 2yo
Microchip noted on Intake? neg
Microchip Number (If Applicable):

History : O surrender due to having to work too much and can’t afford to care for pet. Reportedly constipated x 3 weeks. O gave unknown laxative causing recent bowel movement.

Subjective: BARH, friendly and well behaved during PE.

Observed Behavior –

Evidence of Cruelty seen – n

Evidence of Trauma seen – n

Objective

T =
P = wnl
R = eup
BCS 4/9

EENT: Eyes clear. Ears clear. No nasal or ocular discharge noted
Oral Exam: neg oral, clean dentition
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated. Small amount of feces. Small soft bladder.
U/G: FI, no MGTs, no vulvar dc
MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal: normal externally

Assessment:
Hx of constipation, but not currently
Apparently healthy

Prognosis: excellent

Plan:
plan for OHE

SURGERY:
Okay for surgery

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