ENCHILADA – 20547
Urgent - Manhattan
SUPER URGENT 2/14/18
ENCHILADA – 20547
Care Center Location: Manhattan, ZIP Code From: 10453, Intake Type: Stray
Medical Behavior: Yellow, Age: 10 years, Sex: Female, Weight: 13 lbs
DVM Intake Exam; Estimated age:8-10y; Microchip noted on Intake? n; History :stray; Subjective: very matted. rear feet possibly strangulated. OD corneal ulceration secondary to matting. Hematochezia during exam; Observed Behavior -allowed most handling, growl when anal area examined; Evidence of Cruelty seen neglect; Objective ; T =; P =60; R =wnl; BCS 5/9; EENT: Ou sclerosis, od corneal ulceration. was matted shut, ears clean, no nasal or ocular discharge noted; Oral Exam: severe ddz; PLN: No enlargements noted; H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic; ABD: Non painful, no masses palpated; U/G: nmo ss seen; MSI: severe matting esp rear legs, fleas, fad; CNS: Mentation appropriate – no signs of neurologic abnormalities; Rectal: anal area caked with feces, moist dermatitis; Assessment: matting, dermatitis, corneal ulceration, fad; Prognosis: fair; Plan: shave, clavamox 62/g mg bid , tab od bid; Permanent waiver due to age
A Little Bit About Me…
A staff member writes: Enchilada was found as a stray and brought to ACC when the finder had no luck finding her owner. Enchilada is a sweet girl that will need follow up medical care (please see medical below)
My medical notes are…
Progress Exam: Vet Notes: 11:58 AM; Presented severely matted with corneal ulcer OS secondary to matted; was shaved yesterday; S/O; -QAR/BAR, allows handling -good appetite -mm pk, sl tacky -no nasal discharge or sneezing -OD: cornea appears dull with mucoid discharge and mild to moderate corneal edema; -OS: immature cataract, superficial corneal defect present in dorsal field; -eupnic, clear lung sounds, no murmurs/arrhythmias -soft abdomen -5 firm, small (<0.5 cm) mammary gland tumors associated with 2nd most caudal glands on L chain; one firm, small SQ tumor associated with mid gland on R chain; A; 1. KCS OD, suspected 2. Corneal ulcer OS 3. Mammary gland tumors, small, non ulcerated, multiple 4. Geriatric; P -optimmune OU in right eye -continue TAB ointment and clavamox -recommend removal of L mammary chain and local excision of MGT on R side after placement -prognosis: guarded, depends greatly on behavior of MGT but concern for malignancy due to multiple tumors present
Details on my behavior are…
Date of assessment: 15-Feb-2018
Look: 1. Dog’s eyes are averted, ears are back, tail is down, relaxed body posture. Dog allows head to be held loosely in Assessor’s cupped hands.
Sensitivity: 1. Dog stands still and accepts the touch, eyes are averted, and tail is in neutral position with a relaxed body posture. Dog’s mouth is likely closed for at least a portion of the assessment item.
Tag: 1. Dog follows at the end of the leash, body soft.
Paw squeeze 1: 2. Dog quickly pulls back.
Paw squeeze 2: 2. Dog quickly pull back.
Toy: 1. No interest.
Summary: Enchilada approached the assessor in the assessment room with a soft body. She was social, allowed all handling, and displayed no concerning behaviors.
Summary (1): 2/15: When introduced off leash to dogs, Enchilada keeps mostly to herself.
Summary (2): 2/16: Enchilada keeps mostly to herself.
Date of initial: 13-Feb-2018
Summary: Enchilada allowed most handling but growled when her rear end was handled.
ENERGY LEVEL: We have no history on Enchilada so we cannot be certain of her behavior in a home environment. In the care center, she displays a medium level of activity.
BEHAVIOR DETERMINATION: AVERAGE (suitable for an adopter with an average amount of dog experience)
Behavior Asilomar; H – Health
You may know me from such films as…
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