CECE – A1112814
Safe - 5-25-2017 Brooklyn
CECE – A1112814
FEMALE, BROWN, CHIHUAHUA SH MIX, 10 yrs
OWNER SUR – AVAILABLE, NO HOLD Reason MOVE2PRIVA
Intake condition GERIATRIC Intake Date 05/25/2017, From NY 11234, DueOut Date 05/25/2017,
Medical Behavior Evaluation BLUE
Medical Summary 05/24/17 DVM Intake Exam Estimated age: 10 yrs Microchip noted on Intake? No. History : Brought in by owner, no medical concerns noted. Subjective: Observed Behavior – Very nervous, tense and trembling. Allows all handling. Objective: BARH. mm=pink, moist, CRT<2 s. HR=120, RR=28. BCS=5/9. ORAL: Mod. calculus and gingivitis. EENT: Eyes clear, ears clean, no nasal discharge noted. PLN: No enlargements noted. H/L: Lungs clear, Gr 2/6 left sided systolic murmur. ABD: Non painful, no masse/organomegaly palpated. U/G: Female, no spay scar found. MS: Ambulatory x 4, no lameness. INTEG: Full, clean haircoat. No skin lesions. Very long toenails. CNS: Mentation appropriate – no signs of neurologic abnormalities. A: 10 yr old dog with dental disease and heart murmur. R/o mitral valve disease. P: Permanent waiver from OVH surgery due to age and heart murmur. Monitor while at BACC. Good prognosis with appropriate management. Rec. cardiac consult and dental cleaning.
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