ANTONIO -30772
Safe - 6-14-2018 Manhattan
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SAFE 06/14/18
ANTONIO -30772
Care Center Location: Manhattan; ZIP Code From: 10029; Intake Type: Stray
Medical Behavior: Blue; Age: 12 years; Sex: Male; Weight: 8 lbs
DVM Intake Exam:Estimated age: geriatric adult, ~ 12+. Microchip noted on Intake? scan negative Microchip Number (If Applicable): placed on intake # History: stray Subjective: QARH. Observed Behavior – calm/friendly. Objective: P/RR wnl BCS 3/9 EENT: OU mild nuclear sclerosis, mod crusting ocular d/c with periocular alopecia and ulcerative lesions; AU clean. Oral Exam: severe dental dz/gingivitis ,very sensitive to oral exam (limited), small soft tissue swelling below right eye r/o tooth root abscess vs other PLN: enlarged submandib. LN, nosf H/L: nsf. NSR, NMA, CRT < 2, Lungs clear, eupnic. ABD: soft, non painful, no masses palpated. U/G: intact male MSI: long nails, Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat. CNS: Mentation appropriate – no signs of neurologic abnormalities Rectal: externally normal Assessment: severe dental dz with poss. tooth root abscess + periocular alpecia/lesions r/o allergic vs metabolic vs other + skinny BCS + long nails (trimmed). Prognosis: open Plan: Give 0.85 ml Clavamox (62.5 mg/ml) PO BID x 14 days + 0.25 ml Metacam PO SID x 5 days + TAB ointment applied around both eyes BID x 7 days + monitor weight + recheck mouth and eyes. + rec’ NH placement SURGERY: Permanent waiver due to age/health
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