GABRIELA – A1099007

GABRIELA – A1099007

FEMALE, BROWN / WHITE, CHIHUAHUA SH MIX, 15 yrs
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition GERIATRIC Intake Date 12/07/2016, From NY 10474, DueOut Date 12/10/2016,

Medical Behavior Evaluation BLUE
Medical Summary 12/7/16 Sex: Female, in heat Scan: Negative Estimated age: 12-15 years based on dentition, arthritis, fur color and general condition Fleas: No flea dirt. S: Quiet, wary, allows handling with tense body language O: BAR-H, BCS 5/9 with some muscle wasting, MMs pink EENT: No discharge OU, AU. Mild serous nasal discharge. Severe tartar, gingival recession and gingivitis. Small round dermal mass dorsal to left eye – white dry and crusty overlying skin. PLNs: Popliteal LNs enlarged and symmetrical. H/L: Grade 3/6 systolic heart murmur PMI L apex. NSR. Eupnic. Abd: Full, no pain on palpation, no masses palpated M/S/I: Stands with right front leg abducted at the shoulder. No crepitus or swelling palpated. Bilateral medial patellar luxation grade 3/4, moderate crepitus. Thin fur coat on trunk. Interdigital skin on both hind feet is erythematous. Decubital ulcer on left hock – alopecia and thin skin. UG: Female. Soft nipples with no masses. Vulva mildly enlarged with thin serosanguinous discharge. A: 1. Heart murmur 2. Severe dental disease 3. Medial patellar luxation – bilaterally grade 3/4 4. Abduction at right shoulder – R/O arthritis 5. In heat 6. Small dermal mass on skull 7. Thin fur on trunk – R/O age-related change vs. endocrine disease 8. Popliteal lymphadenopathy – R/O related to inflammation in stifles from patellar luxation vs. infection/inflammation in other area of body Short-term prognosis: Fair Current surgery status: Temporary waiver for age P: 1. Administered pyrantel 0.5 ml PO and Activyl 4-14# during exam 2. CBC/chemistry 3. Recommend evaluation by cardiologist and consider dental cleaning with proper anesthetic management – many extractions will be needed 4. Consider analgesics or alternative therapies for arthritis in stifles and right shoulder 1088
Weight 8.4

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