SCOTTIE aka VELMA – 22199
RTO SAFE 03/08/18
SCOTTIE aka VELMA – 22199
Care Center Location: Manhattan, ZIP Code From: 10029, Intake Type: Stray
Medical Behavior: Green , Age: 8 years, Sex: Neutered male, Weight: 17 lbs
DVM Intake Exam; Estimated age: 8 yo; Microchip noted on Intake? yes; History : stray, coughing; Subjective: BAR. Sweet and friendly, well behaved during PE and med handling, no signs of aggression. Observed Behavior -Objective T = P = wnl; R = wnl; BCS 2/9; EENT: Both eyes have the same ocular changes – fixed dilated pupils, negative PLRs, normal tapetal reflections, incipient cataracts, +/- lens luxations, and the entire posterior (and anterior?) chamber has a “starry” speckled appearance. AS clear, AD had a thick ceruminous hair matt in inner ear canal which was removed. No nasal or ocular discharge noted. Cough elicited on tracheal palpation. Oral Exam: severe dental disease. several teeth missing. mandibular prognathism. PLN: No enlargements noted; H/L: Grade V/VI left systolic HM, NSR. Strong and synchronous femoral pulses. MM pink, CRT < 2. Lungs clear, no crackles or wheezes noted, eupnic; ABD: Non painful, no masses palpated; U/G: MN; MSI: Ambulatory x 4, skin free of parasites, no masses noted, fair hair coat with some matting ventrally.; CNS: Mentation appropriate – no signs of neurologic abnormalities; Rectal: normal externally, feces around perianal area; Assessment: coughing — r/o CIRDC/kennel cough vs collapsing trachea vs heart failure; HM; geriatric; ocular disease; emaciated/muscle wasted; dental disease; Prognosis: guarded, depending on the results of cardiology work-up; Plan: – move to ISO; – cbc/chem; – doxycycline 100mg PO SID x 14 days ; – 2 view CXR tomorrow, include neck. Unable to do today due to staffing. If coughing is related to cardiac disease or collapsing trachea and not CIRDC, move p out of ISO and consider discontinuing doxycycline. ; – Recommend cardiology and ophthalmology consult as soon as p is placed or adopted. ; – Updated NH on p’s case and need for further work-up by specialists ; SURGERY: Permanent waiver due to HM and age
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