DOVER – A1118567 

DOVER – A1118567

MALE, BLACK / WHITE, POINTER, 16 yrs
STRAY – STRAYAVAI, HOLD FOR ID Reason STRAY
Intake condition EXAM REQ Intake Date 07/15/2017, From NY 10029, DueOut Date 07/18/2017,

Medical Behavior Evaluation BLUE
Medical Summary DVM Intake Exam Estimated age: Microchip noted on Intake? yes 432A7B54OC History : found by individual on highway, brought into medical on cart/stretcher- very stressed, panting, appeared weak sitting sternally, by time reached medical was able to walk weakly into medical, at first flopped to floor Subjective: Observed Behavior – very nervous, barking, needed muzzle  Objective T = 100 P = panting cannot ascult R = panting BCS 3.5/9 EENT: nuclear sclerosis ou, ears clean, no nasal discharge noted Oral Exam: muzzle on, didn’t examine PLN: No enlargements noted H/L: panting healvily unable to ascult for cardiac sounds, as exam went on, p calmed down and then was panting less ABD: Non painful, no masses palpated U/G: grossly normal MSI: Ambulatory x 4 with HL weakness and stiff gait, long nails, dirty furcoat, two approx 4cm SQ soft masses on ventral abn, and an approx 2cm SQ soft mass on dorsal aspect of L FL carpus. Seems sensitive when L FL attempted to be palpated, but can place weight on it, no obvious lesions noted during limited exam, normal skin tent CNS: appeared distressed when first entered ACC, then nervous, and finally appeared exhausted and then allowed some exam, no obvious neuro deficits seen at this time Rectal: not performed offered vienna sausage and canned food- didn’t eat Assessment underconditioned multiple masses: r/o benign vs. malignant stressed, weak, some improvement once calmed down r/o orthopedic injury (OA, fx, displacement, other) vs soft tissue vs. neuro vs. other Plan cut nails gave 300ml LRS SQ- did not give more as couldn’t ascult for cardiac sounds well mirtazipine 15mg: 1T PO SID x2 check app cbc/chem in house re assess in 24 hrs when hopefully calmer to determine if needs further meds/dx’s/tx, complete an orthopedic exam Prognosis: open SURGERY: Permanent waiver due to geriatric condition
Weight 0.0

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