COCONUT – A1112985
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COCONUT – A1112985
NEUTERED MALE, WHITE, MALTESE MIX, 13 yrs
STRAY – AVAILABLE, HOLD RELEASED Reason OWNER DIED
Intake condition EXAM REQ Intake Date 05/24/2017, From NY 10027, DueOut Date 05/24/2017,
Medical Behavior Evaluation GREEN
Medical Summary DVM Intake Exam Estimated age: reported to be 13 years; exam consistent with this age Microchip noted on Intake? positive History : owner died Subjective: QAR Observed Behavior – allows handling Evidence of Cruelty seen – Evidence of Trauma seen – Objective BCS 3/9 EENT: OU-crusting tear staining at medial canthus Oral Exam: mm pk, sl tacky; severe dental disease with halitosis PLN: No enlargements noted H/L: grade V/VI heart murmur; eupnic with normal lung sounds ABD: soft, nonpainful; slightly doughy, no palpable abnormalities U/G: neutered male MSI: ambulatory x 4, mild kyphosis of TL spine; decreased hip extension with mild discomfort (worse on R) diffuse muscle wasting, spine visible mild ataxia nails overgrown CNS: slightly abnormal mentation with mild ataxia Rectal: not performed Assessment Heart murmur-r/o valvular disease vs other Periodontal disease Muscle wasting-r/o systemic dz vs paraneoplastic vs other Ataxia/abnormal mentation-r/o poss decreased vision vs secondary to systemic dz vs primary neurologic Plan trimmed nails Rec’d CBC/chem Rec’d CXR and ideally further cardiac work up including EKG, BP and echo Rec’d neuro consult if ataxia progresses Rec’d dental cleaning with extractions if okay to proceed with anesthesia after cardiac work up and bw Prognosis: open SURGERY: neutered
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