EMERY – A1126455

EMERY – A1126455

FEMALE, BROWN / BLACK, POODLE MIN / POMERANIAN, 11 yrs
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition EXAM REQ Intake Date 09/24/2017, From NY 10459, DueOut Date 09/27/2017,

Medical Behavior Evaluation No Initial Behavior
Medical Summary DVM Intake Exam Estimated age: 13-15 years Microchip noted on Intake? History : stray dog, no further information available Subjective:QAR Observed Behavior – lethargic, docile, allows all handling; blind  Objective BCS 3/9 EENT: OU-hypermature cataracts, menace neg OD-lateral strabismus, irregular pupil/iris, poss lens luxation no nasal discharge AU-clear Oral Exam: mm lgt pk/pigmented, tacky; severe dental disease with discoloration of enamel; firm swelling along R TMJ/under eye, severe halitosis; suspect tooth root abscess PLN: No enlargements noted H/L: grade V/VI heart murmur, eupnic, normal lung sounds ABD: nonpainful, doughy; no palpable abnormalities U/G: intact female MSI: ambulatory paraparesis, prefers to lie down gd ROM in hips, stifles kyphosis of TL spine, no obvious discomfort diffuse muscle wasting CNS: paraparesis, delayed CP/decreased withdrawal on hind limbs; lateral strabismus OD Rectal: not performed, grossly normal Assessment Firm facial swelling-suspect tooth root abscess, r/o boney tumor vs previous trauma vs other Dental disease-severe Heart murmur-r/o valvular vs other Cataracts Strabismus/pupil abnormality OD-r/o nerve damage secondary to poss tooth root abscess vs other Muscle wasting Paraparesis-r/o chronic IVDD vs intracranial vs other Plan CBC/chem clindamycin 25 mg/ml: 1.3 ml PO BID x 14 days gabapentin 250 mg/5 ml: 0.5 ml PO BID x 7 days further tx and recommendations pending bw Prognosis: guarded to fair SURGERY: permanent waiver due to age/heart murmur
Weight 6.5

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