BARCLAY – 22149
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SAFE 03/16/18
BARCLAY – 22149
Care Center Location: Manhattan, ZIP Code From: 10460, Intake Type: Stray
Medical Behavior: Green , Age: 12 years, Sex: Male, Weight: 7 lbs
DVM Intake Exam; Estimated age: 12 yo; Microchip noted on Intake? neg History : stray, police found dog wandering on the street; Subjective: BAR, friendly and well behaved during PE and vaccination, but p was very tense and shaking.; Observed Behavior – Objective ; T =; P = wnl; R = wnl; BCS 4/9; EENT: OU nuclear sclerosis and dried black discharge along medial canthi, ears clear, no nasal discharge noted; Oral Exam: severe dental disease; PLN: No enlargements noted; H/L: Grade III/VI left systolic HM, NSR. Lungs clear, eupnic; ABD: tense but Non painful, no overt masses palpated, difficult to palp deeply; U/G: MI. 2 testicles of uneven size, right testicle enlarged. MSI: Ambulatory x 4, skin free of parasites, no masses noted, unkempt dirty matted hair coat, especially on all 4 limbs.; CNS: Mentation appropriate – no signs of neurologic abnormalities; Rectal: normal externally; Assessment: geriatric; nuclear sclerosis; HM; matted; uneven testicles, right one enlarged — r/o neoplasia vs other; Prognosis: guarded, pending a cardiology and IM eval; Plan: ctm until transfer/adoption; scheduled shave hair matts; Recommend cardiology and IM consult; SURGERY: Permanent waiver due to age and HM
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