CEASAR – A1111754

CEASAR – A1111754

MALE, BLACK, POODLE TOY MIX, 9 yrs
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition EXAM REQ Intake Date 05/11/2017, From NY 10454, DueOut Date 05/14/2017,

Medical Behavior Evaluation GREEN
Medical Summary  Estimated age: Estimated 7-12 years based on overall appearance Microchip noted on Intake? Negative – placed MC during exam.  Stray, no hx given.  Timid, shivering, allows all handling  BCS 3.5/9, MMs pink EENT: Eyes clear, ears fur-filled, no nasal discharge noted Oral Exam: Severe tartar PLN: Mandibular LNs subjectively enlarged and firm H/L: Grade 3/6 systolic heart murmur PMI *RIGHT* heart base. NSR. Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: Male intact, testicles S/S MSI: Ambulatory x 4. Alopecia over most of the body with crusty dry skin, hyperpigmentation, lichenification. CNS: Mentation appropriate – no signs of neurologic abnormalities Assessment: 1. Underweight 2. Dental disease 3. Alopecia and dermatitis – R/O endocrine vs. allergic vs. alopecia X vs. other cause 4. Heart murmur Plan 1. Simplicef 25 mg PO SID x10 days, may be extended if effective 2. Bathe with Mal a Seb shampoo every other day, follow with moisturizing soothing lotion if available 3. CBC/chemistry/T4 4. Recommend chest rads and echocardiogram Prognosis: Fair-poor SURGERY: Permanent waiver due to heart murmur. 1088
Weight 5.6

 

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