REMY – 24794
Safe - 4-17-2018 Manhattan
REMY – 24794
Care Center Location: Manhattan, ZIP Code From: 10032, Intake Type: Stray
Medical Behavior: Blue, Age: 11 years, Sex: Neutered male, Weight: 15 lbs
DVM Intake Exam; Estimated age: 11y provided by O; consistent with PE based on ocular and dental changes. Microchip noted on Intake? Scanned negative. History : surrendered by O; O placed in nursing home. Subjective / Observed Behavior – BAR, barking in kennel, panting, very active. allows all handling but pulled away for oral exam. Objective ;BCS 7/9 ;EENT: bilateral cataracts; 3mm mass along the left dorsal eyelid; mild brown exudate, AU with thickening of the pinna. no nasal or ocular discharge noted; Oral Exam: dc 3/5; periodontal dz 3/5 ;PLN: No enlargements noted; H/L: NSR, NMA, CRT < 2, Lungs clear,eupnic; occasional cough especially when pulling on lead. ABD: Non painful, abdomen is tense; unable to palpate organs. U/G: neutered. penis is normal, grossly. MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat; 2inch cysts along the dorsal head (straw colored fluid) CNS: Mentation appropriate – no signs of neurologic abnormalitiesRectal: grossly normal. Assessment; cataracts, bilateral. eyelid mass – r/o adenoma ;otitis externa; dental calculus ; periodontal dz ; overweight ; cyst — drained. intermittent cough — suspect collapsing trachea ; Prognosis: good ; Plan: nail trim — performed at intake. ear cleaning ; mometamax; rec dental cleaning under GA once placed ;consider eyelid mass removal ;monitor coughing for signs of CIRDC ;SURGERY: already neutered
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