SPUD – 17970
Safe - 1-18-2018 Manhattan
SPUD – 17970
Care Center Location: Manhattan, ZIP Code From: 10454, Intake Date: 1/9/18
Intake Type: Stray, Medical Behavior: Green, Age: 12 years, Sex: Male, Weight: 12 lbs
DVM Intake Exam; Estimated age: 10-12 years; History : found in apartment after owner passed away; unsure of how long ; Subjective:QAR; Observed Behavior -docile, allows all handling; good appetite overnight, small clear/yellow urination on blankets; Objective ; BCS 5/9; EENT: OU-corneas dull with mucoid discharge and mild corneal edema; Oral Exam:mm pk, tacky; CRT <2 sec; severe dental disease ; PLN: No enlargements noted; H/L: no murmurs or arrhythmias, clear lungs; ABD: Non painful, no masses palpated; U/G: male neutered; MSI: ; -ambulatory x 4 with mildly decreased weight bearing on LH; hyperextension of hindlimbs; -LH: grade II MPL with mild crepitus; mild dec hip extension with slight discomfort; mildly decreased tarsal flexion; -mild TL discomfort; CNS: Mentation appropriate, mildly delayed CP on LH; Rectal:grossly normal; Assessment; 1. KCS, suspected; 2. Dental disease; 3. L MPL, mild lameness, suspect concurrent arthritis; 4. TL pain, mild-r/o chronic IVDD vs other; Prognosis:fair to good. Plan:-optimmune OU BID-recommend geriatric blood work (unable to run due to machine malfunction) and dental cleaning after placement-gabapentin 50 mg/ml: 0.5 ml PO BID, if responds well then consider using long term for suspect arthritis and mild spinal discomfort
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