SYLVIA PLATH – A1121286
Safe - 8-9-2017 Manhattan
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SYLVIA PLATH – A1121286
FEMALE, TAN, CHIHUAHUA SH MIX, 13 yrs
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition EXAM REQ Intake Date 08/08/2017, From NY 10458, DueOut Date 08/11/2017,
Medical Behavior Evaluation GREEN
Medical Summary DVM Intake Exam Estimated age: 9-10 yearsMicrochip noted on Intake? no History : found as stray Subjective: QAR, hydrated Observed Behavior – A little anxious but friendly, allows petting, exam and treatments with minimal restraint Objective P = 110 R = 20 BCS: 5/9 EENT: Eyes clear, evidence of chronic tearing, ears clean, no nasal discharge noted Oral Exam: Missing most of her teeth, remaining teeth have periodontal disease and gingivitis PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: female, linea scar palpable, no mgts or dc MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat CNS: mentation appropriate – no signs of neurologic abnormalities Rectal: not performed Assessment: older female/spayed chihuahua with periodontal disease and oligodontia. Appears to be in good health despite poor dentition. Plan: vaccinate microchip deworm flea tx heartworm test recommend periodontal evaluation/treatment Prognosis: good SURGERY: suspect already altered
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