CATALINA – A1111893

CATALINA – A1111893

FEMALE, WHITE, MALTESE MIX, 10 yrs
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition UNSPECIFIE Intake Date 05/12/2017, From NY 11233, DueOut Date 05/15/2017,

Medical Behavior Evaluation GREEN
Medical Summary DVM Intake Exam Estimated age: Over 10 yo Microchip noted on Intake: Negative History: Stray Subjective: Observed Behavior – QAR, does not mind to be handle  Objective: Hydrated; T =Not taken P =130 R = 36 BCS 5/9 EENT: Eyes clear, nuclear sclerosis, ears are dirty, large brown discharge AD, no nasal discharge noted Oral Exam: Severe dental disease, heavy dental tartar and gingivitis, missing some permanent teeth, MM Pink and moist, PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: Intact female MSI: Ambulatory x 4, skin free of parasites, no masses noted, matted hair coat CNS: Mentation appropriate – no signs of neurologic abnormalities (full neurologic exam not performed) Rectal: Not performed Assessment 1. Geriatric 2. Severe periodontal disease Grade 4/4 3. Otitis extrana AD 4. Arryhrnia (r/o synus arrthythmia) 5. Head tilted to the left r/o vestibular disease vs otitis externa Plan/Treatment/Recommendations Plan – Wt: 9.0 lb – HWT snap test (negative) – Vaccines (DAPP SQ RFL; Bordetella IN; Rabies SQ RHL) – Dewormed (Pyrantel) – Flea prevention treatment – Microchip place (Between shoulder blades):981020021184277 -Clean both ears (done) -Otibiotic AD BID 10 days Prognosis:Fair SURGERY: Rec HP placement Permanent waiver due to age
Weight 9.0

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