CHLOE – A1122902

CHLOE – A1122902

FEMALE, GRAY / TAN, YORKSHIRE TERR, 10 yrs
OWNER SUR – WAITING4PU, HOLD RELEASED Reason PET HEALTH
Intake condition EXAM REQ Intake Date 08/22/2017, From NY 10458, DueOut Date 08/23/201

Medical Behavior Evaluation GREEN
Medical Summary  Estimated age: 4 per intake sheet, looks much older Microchip noted on Intake? yes 046 060 886 History : surrender, no history avail. at time of exam Subjective: depressed, dehydrated, weak Observed Behavior – weak, quiet, minimally responsive  P = 110 R = 15 BCS: 2/9 EENT: bilateral corneal ulcers, mucopurulent discharge OU, ears clean, no nasal discharge noted Oral Exam: within normal limits PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: female intact suspected, no mgts or dc MSI: weakly ambulatory, needs assistance to stand,, skin free of parasites, no masses noted, missing hair/scar along dorsal T/L spine CNS: dull, slightly ataxic, no obvious cp deficits, prefers recumbency. Assessment: geriatric yorkie, with bilateral corneal ulceration, very weak, very thin to cachectic, possible neurologic/ataxic: rule out metabolic disease vs infectious vs inflammatory vs other Plan: 15 ml warm LRS sq treat corneal ulcerations run full bloodwork needs medical monitoring, consider xrays pending bloodwork results. Prognosis: poor SURGERY: Permanent waiver due to age/condition Addendum: CBC: within normal limits Chem: mildly elevated globulins, remaining values all within normal limits. Recommend monitor appetite/attitude, treat corneal ulcers, consider neuro consultation.
Weight 4.1

 

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