WILLIE – 19926
Safe - 2-11-2018 Manhattan
WILLIE – 19926
Care Center Location: Manhattan, ZIP Code From: 10458, , Intake Type: Owner surrender,
Medical Behavior: Blue, Age: 10 years, Sex: Neutered Male, Weight: 14 lbs
DVM Intake Exam; Estimated age: Reported 10 years old; Microchip noted on Intake? Scanned POSITIVE on intake; History : Surrendered. Pt fell from a window a few years ago and was injured on his face – he was taken to the hospital – but that is why he has alopecic scars on his face; Subjective: Alert, calm; Observed Behavior – Allows all handling. Not tense but stands still and allows handling. Objective ; BAR-H, MMs pink and moist, BCS 5/9; EENT: Areas of black skin (hyperpigmentation) and alopecia on each side of the nose, just lateral to the nasal planum. Area of alopecia but normal skin pigmentation and no erythema at the medial canthus OS (2 cm dia). Eyes clear, ears clean, no nasal or ocular discharge noted; Oral Exam: Severe tartar and moderate gingival recession.; PLN: No enlargements noted; H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic; ABD: Non painful, no masses palpated; U/G: Male neutered; MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy and very fluffy hair coat; CNS: Mentation appropriate – no signs of neurologic abnormalities; Rectal: Normal externally; Assessment: 1. Geriatric but no sign of chronic health condition; 2. Dental disease; 3. Scars on face from prior injury; no current medical issues in this area; Prognosis: Good; Plan: 1. Recommend dental cleaning and daily tooth brushing
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