BOOBOO – A1113218

BOOBOO – A1113218

MALE, BROWN / GRAY, YORKSHIRE TERR MIX, 13 yrs
OWNER SUR – EVALUATE, HOLD FOR ID Reason PERS PROB
Intake condition GERIATRIC Intake Date 05/26/2017, From NY 10472, DueOut Date 05/26/2017,

Medical Behavior Evaluation GREEN
Medical Summary DVM Intake Exam Estimated age: 13 Microchip noted on Intake? none on intake History : o surrender Subjective: Observed Behavior – allows all handling, docile  Objective P = 150 R = 30 BCS 5/9 EENT: Eyes clear, ears clean, no nasal discharge noted Oral Exam: severe dental tartar, recessed gums with moderate gingivtis, oligodontia L upper dental arcade, tongue sticking out of L side of mouth, no obvious oral tumors PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: MI, both testicles descended, normal consistency MSI: Ambulatory x 4, skin free of parasites, no masses noted, alopecia along entire dorsum, tail- skin beneath NSF, pot bellied appearance, three approx 2mm pink ceribriform masses: one on caudal aspect of head, another on lumbar spine, and one ventral to anus. Moderate crepitus R stifle- grade 2/4 MPL CNS: mentation appropriate – no signs of neurologic abnormalities Rectal: feces in colon, no pain, no abN detected Assessment R stifle OA and MPL grade 2/4 severe dental dz and moderate periodontal dz, oligodontia suspected Cushing’s MI Plan rec cbc/chem/t4/ua as general health screen and likely ACTH stim test (to test for Cushing’s disease), possible abdominal ultrasound ideally would get dental px with extractions, but given age and likely underlying condition, rec first determine if good candidate for general anesthesia rec joint supplements and pain meds as needed if any limp if cannot pursue workup would be reasonable to keep p comfortable for the rest of its life ensuring p eating, has any pain addressed, etc. alerted NH of p status Prognosis: fair SURGERY: Permanent waiver due to old age
Weight 12.1

 

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