TYLER BREEZE – 18876

Estimated age: Approx. 4-5 yrs
Microchip noted on Intake? No

History : Surrendered, no known history

Subjective: BAR on presentation, timid, but allows handling

Observed Behavior – Patient will not seek affection but will allow handling, only light restraint needed.

Evidence of Cruelty seen – No

Evidence of Trauma seen – No

Objective
P = 240 bpm
R = eupneic
BCS = 5-6/9

EENT: Eyes clear, ears clean, no nasal or ocular discharge noted
Oral Exam: Grade II-III/IV periodontal disease noted.
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated, kidneys S+S
U/G: MN
MSI: Ambulatory x 4, skin free of parasites, no masses noted, Mild flaking noted.
CNS: Mentation appropriate – no signs of neurologic abnormalities

Assessment: Middle aged MN DSH with moderate periodontal disease and mild skin flaking (r/o secondary to diet vs. stress vs. weather vs. other)

Prognosis: Good

Plan:
Continue to monitor while in BACC. Medically ok to make available. Recommend dental upon placement.