MIZA – A1020035
Safe - 5-26-2017 Manhattan
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MIZA – A1020035
SPAYED FEMALE, WHITE, MALTESE, 5 yrs
OWNER SUR – ONHOLDHERE, HOLD FOR ID Reason NO TIME
Intake condition EXAM REQ Intake Date 05/20/2017, From OUT OF NYC, DueOut Date 05/20/2017,
Medical Behavior Evaluation GREEN
Medical Summary DVM Intake Exam Estimated age: 5yr Microchip noted on Intake? yes History : was living with o’s father, brought back to ACC because vomiting intermittently over past two yrs and losing weight in spite of appetite Subjective: Observed Behavior – docile, allows all handling as o states p has been vomiting for past two years- r/o reason for emaciation Objective P = 100 R = 24 BCS 2.5/9 EENT: Eyes clear, ears clean, no nasal discharge noted Oral Exam: moderate tartar and gingivitis PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: FS, grossly normal, no palpable MGTs MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat, BCS 2.5/9 CNS: mentation appropriate – no signs of neurologic abnormalities Assessment V: r/o IBD, other (neoplasia, metabolic/endocrine) emaciated: r/o secondary to underlying condition moderate dental and periodontal dz Plan requested CBC/chem check V Canine Fortiflora one packet in food SID contacted NH for possible placement, AUS, B12/folate, consider hypoallergenic diet, monitor weight, depending on frequency of V, consider anti emetics not a priority- but long term would benefit from dental px for oral health Prognosis: open pending test results and response SURGERY: Temporary waiver due to emaciation
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View all entries in: Safe Dogs 2017-05