BAISLEY – A1121694
Urgent - Manhattan
SUPER URGENT 08/12/17
BAISLEY – A1121694
*** LEGAL HOLD RELEASED ***
FEMALE, BLACK / BROWN, GERM SHEPHERD MIX, 10 yrs
STRAY – ONHOLDHERE, HOLD FOR ID Reason STRAY
Intake condition EXAM REQ Intake Date 08/12/2017, From NY 11434, DueOut Date 08/18/2017,
Medical Behavior Evaluation BLUE
Medical Summary DVM Intake Exam Estimated age: geriatric, ~ 10-12 yrs Microchip noted on Intake? scan positive AVD 028059121 History : found stray by police, wandering street Subjective: Quiet, moderately depressed, weak Observed Behavior – calm, allowed all handling, only turned to nip when palp hind end and handling for vax/treatments, may need muzzle. Seems very sensitive to heavy touch Evidence of Cruelty seen – poss. neglect, emaciated BCS Evidence of Trauma seen – no Objective T= 99.4 P = 108 R = 36 BCS 1/9 EENT: OU nuclear sclerosis/cloudy lens; AU mild dark brown waxy d/c; no nasal discharge noted Oral Exam: heavily worn down teeth with canines worn about 1/2 way PLN: No enlargements noted H/L: nma, CRT 2-3 sec, Lungs mild incr. lung sounds, nsf ABD: tucked abdomen, emaciated body condition, non-painful, no masses palpated U/G: presumed intact, prominent nipples; did not shave for spay scar MSI: emaciated/cachectic body condition, severe generalized muscle wasting, ambulatory x 4 but reluctant to stand walk for long, gets tired, sits and lays down; sensitive to touch of hindlimbs, no obvious signs of trauma or injury, did not try to flex/extend hips due to sensitivity; small healing laceration on left front paw between 3-4 digits; skin free of parasites, no masses noted, hair coat is dirty and mildly oily to touch CNS: mentation appropriate – no signs of neurologic abnormalities Rectal: not performed Assessment: older/geriatric dog in emaciated body condition – underlying cause unknown – r/o malnutrition/starvation, infect/inflam dz, metabilic disorder vs other – ate a few treats during intake + good appetite for soft food Plan: – photos taken of BCS and left front paw wound – run complete bloodwork – monitor appetite and weight Prognosis: open SURGERY: Permanent waiver due to age/health.
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