BROOKLYN – 19862
Safe - 4-6-2018 Brooklyn
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SAFE 04/06/18
BROOKLYN – 19862
Care Center Location: Brooklyn ;ZIP Code From: 11206; Intake Type: Stray
Medical Behavior: Green ;Age: 13 years; Sex: Spayed female; Weight: 30 lbs
DVM Intake Exam: Estimated age: 14 Microchip noted on Intake? n Microchip Number (If Applicable): n History : OS Subjective: BAR Observed Behavior – timid, gentle, allowed for full PE Objective: T = – P = 120 R = WNL BCS = 6/9 EENT: SEVERE otitis externa. Brown discharge. Eyes clear, no nasal or ocular discharge noted. Oral Exam: Moderate/Severe calculus and peridontitis PLN: No enlargements noted H/L: grade 4/6 right side heart systolic murmur, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: Vulva scaling and dry/flaky – non pruritic and non painful MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat. CNS: Mentation appropriate – no signs of neurologic abnormalities. Rectal: n/p Assessment: Severe Otitis Externa Prognosis: Good Plan: Cleaned ears with otic solution and applied Otobiotic in both ears 1) Apply Momentamax SID for 14 days. 2) Clean ears with otic cleaner every 3 days for 3 weeks or until clinical signs stop SURGERY: Permanent waiver due to age and heart murmur
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