AQUARIUS – 15738

AQUARIUS – 15738

Location: Manhattan; Intake Date: 12/09/17; Intake Type: Stray Medical

Behavior: Green; Sex: Spayed; Age: 8 years; Weight: 13 lbs  Zip Code: 11230

Vet Notes: 4:34 PM- DVM Intake Exam: Estimated age: 7-9 years old based on dentition and overall appearanceMicrochip noted on Intake? Scanned neg on intake – MC placed during LVT intake History : Stray, no health hx available Subjective: Timid, alert. Observed Behavior – Allows most handling but struggles for facial exam Objective: BAR-H, MMs pink, BCS 6/9 EENT: OU immature cataracts (approx 60-70% of pupil is covered), corneal opacity, mild corneal keratinization, mild mucoid discharge. Long fur especially around eyes. Ears clean, no nasal discharge noted. Oral Exam: Moderate tartar. PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: Female, presumed intact – developed vulva. No vulvar or mammary masses or discharge. MSI: Copious flea dirt. Some matting. Ambulatory x 4, no masses noted. CNS: Mentation appropriate – no signs of neurologic abnormalities  Rectal: Normal externally. Fluorescein stain – neg OU  Assessment: 1. Dental disease 2. Overweight 3. Cataracts
4. Pattern of corneal keratinization and opacity, and mucoid discharge – R/O exposed corneas and abrasion by fur, vs. KCS vs. other Prognosis: Good  Plan: 1. Recommend dental cleaning and daily tooth brushing  2. Recommend weight loss. 3. Monitor vision, provide a stable home environment so pt can navigate around easily. 4. STT tomorrow SURGERY:  Okay for surgery   1088

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