CARAMEL – 34050
Safe - 7-15-2018 Manhattan
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SAFE 07/15/18
CARAMEL – 34050
Location: Manhattan, Intake Date: 7/11/18, Intake Type: Stray
Medical Behavior: Blue, Sex: Female, Age: 8 years, Weight: 13 lbs
Original Location: 10458
DVM Intake Exam; Estimated age: Estimated 6-10 years old; Microchip noted on Intake? Scanned neg; History : Stray, no health hx available; Subjective: Alert, quiet, slightly tense; Observed Behavior – Slightly tense. Allows all examining but shrieks on blood draw. Objective ; BAR-H, MMs pink, BCS 4/9; EENT: Immature cataract OS; clear OD; no discharge OU. Ears clean, no nasal discharge noted. Oral Exam: Severe tartar and gingival recession; PLN: No enlargements noted; H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic; ABD: Soft, non painful, no masses palpated; U/G: Female, developed nipples, no ventral abd scar. LARGE BLADDER – soft, slightly distended.; MSI: Mild hyperextension of both carpi, possible subtle crepitus on flexion of both joints. No lameness noted. Long nails. Hair coat slightly thin on trunk. Skin free of parasites, no masses noted. CNS: Mentation appropriate – no signs of neurologic abnormalities; Rectal: Normal externally; Assessment: 1. Immature cataract OS; 2. Severe dental disease; 3. Large bladder – R/O simply needs to urinate vs. sign of disease; 4. Mild osteoarthritis in carpi; 5. Long nails; Prognosis: Fair-good; Plan: 1. CBC/chemistry; 2. Trimmed nails during exam; 3. Recommend dental cleaning, monitor for carpal pain and consider pain management strategy; SURGERY: Okay for surgery
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