GRACE – 20978

GRACE – 20978

Care Center Location: Manhattan; ZIP Code From: 11236; Intake Type: Stray

Medical Behavior: Blue; Age: 12 years; Sex: Female; Weight: 8 lbs

DVM Intake Exam:Estimated age: 10-15 years based on dentition and multiple disease processes Microchip noted on Intake? Scanned POSITIVE on LVT intake History : Reported stray, no health hx offeredSubjective: Calm, sits on exam table and waits for handlingObserved Behavior – Passive, allows all handling with no resistanceEvidence of Cruelty seen – Matted, severe dental disease, emaciated. Evidence of Trauma seen – None  Objective:   BAR, BCS 2/9, severe muscle wasting EENT: OU mature cataracts with good PLRs. Fur on ear pinnae appears recently clipped but ear canals are not visible due to fur in them – no erythema or discharge appreciated. Dorsal nose is alopecic and erythematous. No nasal or ocular discharge noted. Oral Exam: Severe tartar accumulation, gingival recession and halitosis – several teeth are loose to the touch. PLN: No enlargements noted H/L: Grade 4/6 systolic murmur, PMI left base. NSR, CRT < 2, Lungs clear, eupnic ABD: Soft, non painful, no masses palpated U/G: Female, no SS palpated, no mammary masses. Large mat obstructing vulva. MSI: Holds hind legs inslight flexion at all times – does not extend them well when walking. No stifle thickening, crepitus or patellar luxation noted. Good PROM in hips and stifles. Fur coat heavily matted on entire body to form a “coat”, especially thick on the legs and tail but no areas of strangulation noted. Long nails. Skin free of parasites, no masses noted. CNS: Quiet, passive. Difficult to tell if mentation is appropriate.  Rectal: Normal externally.

Assessment:

1. Heart murmur
2. Severe dental disease
3. Emaciated
4. Cataracts, appears to be blind
5. Matted – mats obstructing urination and thick around the legs
5. Geriatric

Prognosis: Fair-poor

Plan:
1. CBC/chemistry
2. Groom
3. Recommend cardiac evaluation and subsequent dental cleaning – most teeth will need to be extracted. Pt will be significantly more comfortable after this, and will likely be able to eat hard food again!!
4. Hospice-type care as necessary

SURGERY: Permanent waiver due to age

 

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