BRUCE – A1116482
Safe - 6-28-2017 Manhattan
[email protected] and they will help answer any questions you may have.
BRUCE – A1116482
MALE, TAN, MALTESE MIX, 7 yrs
STRAY – EVALUATE, NO HOLD Reason STRAY
Intake condition EXAM REQ Intake Date 06/25/2017, From NY 11379, DueOut Date 06/28/2017,
Medical Behavior Evaluation BLUE
Medical Summary DVM Intake Exam Estimated age: approx 7-9 years Microchip noted on Intake? neg History : brought in as a stray by a good samaritan who gave him a hair cut prior to intake Subjective: QAR Observed Behavior – easy going, allows handling Objective BCS 4/9 EENT: OU-immature cataracts, mild iris atrophy OD intermittent expiratory cough and reverse sneeze; tracheal sensitivity Oral Exam: mm pk, moist; CRT <2 sec; mod-severe tartar; missing several upper premolars PLN: No enlargements noted H/L: no murmur noted; SNA, SSFP ABD: tense on palpation, no obvious abnormalities U/G: male intact, 2 normal scrotal testicles MSI: ambulatory x 4 with no obvious lameness grade I MPL on L, grade II MPL on R with crepitus ~1 inch, round firm sl ulcerated cutaneous mass at 5 o clock position around rectum CNS: mentation appropriate – no signs of neurologic abnormalities Rectal: not performed Assessment Cough-r/o collapsing trachea vs bronchitis vs CIRDC vs other Rectal mass MPL mod dental disease Plan Rec’d cervical/chest rads to evaluate trachea and lungs Rec’d biopsy of mass prior to excision Rec’d dental cleaning with poss extractions Prognosis: open-need histopath on rectal mass to determine long term prognosis SURGERY: temp waiver due to cough
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