LEESIE – 11501
Safe - 11-5-2017 Brooklyn
LEESIE – 11501
Location: Brooklyn, Intake Date: 11/2/17, Intake Type: Owner Surrender
Medical Behavior: Green, Sex: Female, Age: 12 years, Weight: 8.3 lbs
DVM Intake Exam; Estimated age: 12 years; Microchip noted on Intake? negative; History : o/s ; Subjective: BARH; Observed Behavior – very sweet. Easily handleable. Did well for all medical handling and procedures; Objective ; P = wnl ; R = eupneic ; BCS 4/9; EENT: Eyes clear with nuclear sclerosis ou, ears clean with flea dirt in them, no nasal discharge noted; Oral Exam: adult dentition with mild dental disease, no oral lesions noted; PLN: No enlargements noted; H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic; ABD: Non painful, no masses palpated; U/G: FI, several BB sized MGTs along both mammary chains, no vulvar d/c, large edematous vulva; MSI: Ambulatory x 4, no live parasites but lots of flea dirt, thinning haircoat especially over tail base, unkempt and greasy haircoat, diffuse dermatitis; CNS: mentation appropriate – no signs of neurologic abnormalities; Assessment: Geriatric; MGTs; Dental disease; Nuclear sclerosis OU; Dermatitis r/o FAD vs other allergies; Plan: Continue to monitor while at BACC; Rec surgical removal and histopath of MGTs; Rec 3 view CXR to look for mets and geriatric workup with placement; Strict flea prevention; Bath in 3 days once flea meds have permeated; Prognosis: Fair to good; SURGERY: permanent waiver from surgery due to age
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