SASHE – A1112924
Safe - 5-26-2017 Brooklyn
SASHE – A1112924
NEUTERED MALE, BROWN / WHITE, JAPANESE CHIN / CAVALIER SPAN, 8 yrs
STRAY – ONHOLDHERE, HOLD RELEASED Reason STRAY
Intake condition UNSPECIFIE Intake Date 05/23/2017, From NY 11212, DueOut Date ,
Medical Behavior Evaluation YELLOW
Medical Summary DVM Intake Exam Estimated age: 8+ – marked tartar Microchip noted on Intake? Yes – 985121012506215 History : Stray found in courtyard. Tag traced back to owner – see memo. Owner stated she had a representative to surrender dog. Owner surrender. Brought to medical – apparently vomiting. Subjective: BAR, Overweight, Otitis AD. Observed Behavior – Appears comfortable and wags tail some, but stiffens when leaning over to pet or pick up. Growls when placing hand on side to pick up but allows slow petting of head and top of body. Allows being picked up with towel around him and allows cautious exam. Growls slightly when cleaning ear. Objective T = P = 120 R = eup BCS= 6/9 EENT: Eyes – slight MPOD OS, no discharge OD, mild lenticular changes OU, pupils symmetric, PLR +, cornea/ sclera/ conj clr. Ears – AD – marked black discharge, moderate erythema in canal, minimal swelling/ hyperkeratosis. AS – cln. No nasal discharge noted Oral Exam: Marked tartar especially caudal molars, moderate gingivitis, no missing teeth observed. PLN: No enlargements noted H/L: NSA, NMA,MM pk, CRT < 2, Lungs clear, eupnic ABD: Tense but not painful, no masses. U/G: neutered male MSI: Ambulatory x 4, skin free of parasites, no masses noted, few matts ventrally. Nails very long but not impeding ambulation. CNS: mentation appropriate – no signs of neurologic abnormalities Rectal: not done but dry feces on hair near rectum. Assessment: 8 yo MC Pekingese X Moderate dental dz Otitis externa AD Hx of vomiting but NSF on exam. Plan: Monitor for vomiting. Cleaned R ear. Otobiotic BID x 7 days. Clean ear again in 2 days. Dental prophlaxis recommended but not urgent. Prognosis: Good. SURGERY: already neutered.
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