PAPI – 25555
Safe - 4-20-2018 Brooklyn
PAPI – 25555
Location: Brooklyn, Intake Date: 4/18/18, Intake Type: Owner Surrender
Medical Behavior: Green, Sex: Male, Age: 8 years, Weight: 10 lbs, Original Location: 11433
DVM Intake Exam; Estimated age:8 reported; Microchip noted on Intake?n; History 😮 surrender; Subjective:left front forelimb no CP, knuckled. seems unable to support weight. tense abdomen 9/9 bcs; Observed Behavior -nervous, wags tail; Objective ; T =; P =60; R =increased bronchial noise, 20; BCS 9/9; EENT: Eyes clear, ears clean, no nasal or ocular discharge noted; Oral Exam:severe dental disease; PLN: No enlargements noted; H/L: NSR, NMA, CRT < 2, increased bronchial noise; ABD: very tense abdomen, hard to assess; U/G:2 testes; MSI: Ambulatory x 3, skin free of parasites, no masses noted, dry flaky skin; CNS: no CP rfl, sluggidh cr rhl; radiographs: very large amount of food in stomach but otherwise wnl abdomen. Lungs looks like they had alveolar patten on lateral but look fine on VD view. scapula causing artifact on lateral complicates interpretaion; Assessment: open. neurologic deficit rfl; Prognosis:fair; Plan:repeat radiographs 4/19; SURGERY: Permanent waiver due to infirmity;
Progress exam; History: O/S 4/18. AXR: very large amount of food in stomach, subjectively enlarged liver; CXR: enlarged cardiac silhouette, lungs appear wnl; Subjective: BARH. No csvd. Normal bm and u. Great appetite. Objective: P =wnl; R =wnl; BCS 9/9; EENT: Eyes clear, ears clean, no nasal or ocular discharge noted; Oral Exam: Severe dental disease; PLN: No enlargements noted; H/L: NSR, NMA, CRT < 2, Lungs C&E, barking a harsh bark; ABD: Very tense and distended, difficult to palpate; U/G: MI, 2 testicles descended with mild scrotal dermatitis; MSI: Ambulatory x 3 with knuckling of RFL but positive withdrawal and no pain associated, skin free of parasites, no masses noted, dry flaky skin, obese; CNS: A&A, absent CP RFL but positive withdrawal, no pain in neck or spine, other limbs WNL; Assessment: Hypothyroid; Obese; Neurological deficit RFL; Prognosis: Fair to poor, will need longterm tx; Plan: CBC-nsf; Chem-very mild elevation ALT 130 (10 – 125 U/L); T4-low 0.7 (1 – 4 Âµg/dL); Start treatment for hypothyroidism with placement (no medications available here); CTM while at BACC-rec NH placement; Did not repeat radiographs today since BW was nsf besides hypothyroidism. Rec AUS as it would be more beneficial than repeat radiographs. Had normal BM this morning so stomach is emptying.
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