ESKIE – 23052

ESKIE – 23052

Location: Brooklyn; Intake Date: 3/16/18; Intake Type: Stray

Medical Behavior: Yellow; Sex: Neutered; Age: 10 years; Weight: 25 lbs

Original Location: 11234

DVM Intake Exam: Estimated age: 10+yrs. Microchip noted on Intake? no. Microchip Number (If Applicable):  History: Stray  Subjective: Dog is Q/BARH  Observed Behavior – cries out randomly, difficult to assess if fear or pain related, muzzled as precaution, allows handling with minimal restraint, but does seem uncomfortable (especially around face and pelvic limbs), shaking during entire intake, does not warm up. Objective:  T = NA P = 160 R = wnl. BCS 3-4/9  EENT: Eyes – appears to have immature cataract OD, OS – moderate severe blepharospasm, appears to have corneal edema, attempted to stain eye but third eyelid was protruding and unable to visualize cornea to check for ulcer; ears clean, no nasal discharge noted. Oral Exam: NE (muzzled); halitosis. PLN: No enlargements noted. H/L:  NMA, heart/lungs seem slightly muffled. ABD: No masses palpated. U/G: male, no palpable testicles MSI: Ambulatory x 4; muscle atrophy pelvic limbs, resents palpation (kicks when. RHL touched), approx 2cm cyst-like mass left lumbar area, two lipomatous masses left. thorax, hair coat slightly unkempt (shedding undercoat). CNS: Mentation appropriate – no. signs of neurologic abnormalities. Rectal: not performed. Assessment: Geriatric underlying – suspect cataracts OU +/- trauma to OS, masses (DDx: Cyst, Lipoma(s), MCT, Open). Prognosis:  Fair  Plan: Recommend rescue placement. Start NeoPolyBac – thin strip OS q12h x 7d, then recheck. Consider Trazodone for anxiety. Consider performing bloodwork in. shelter or on placement.  SURGERY:  Appears already neutered

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