HANSEL – A1126370
Safe - 9-26-2017 Manhattan
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HANSEL – A1126370
MALE, GRAY / WHITE, SHIH TZU MIX, 8 yrs
STRAY – ONHOLDHERE, HOLD FOR ID Reason STRAY
Intake condition EXAM REQ Intake Date 09/23/2017, From NY 10469, DueOut Date 09/26/2017,
Medical Behavior Evaluation GREEN
Medical Summary DVM Intake Exam Estimated age: adult approx 8yo MI shih tzu Microchip noted on Intake? pos on intake History : surrender Subjective: BARH, very friendly on intake, allows handling for everything Objective BCS: 5/9 BCS EENT: nuclear sclerosis OU, ears clean, mild serous bilateral nasal discharge noted Oral Exam: 104 and 204 fractured with normal color tooth. 304 and 404 crowns worn flat. healthy gums and minimal tartar. normal undebite. brachycephalic PLN: No enlargements noted H/L: grade III/VI HM Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: Male intact, prostate non painful, no masses palpated MSI: Ambulatory x 4, skin free of parasites, no masses noted, shaved hair coat with matting on all limbs and long nails on all digits CNS: mentation appropriate – no signs of neurologic abnormalities Rectal: no masses, no blood, normal rectal Assessment: adult MI Shih Tzu 1. monitor nasal d/c (consulted with Kristin) 2. Heart murmur 3. mild dental disease 4. hair matting Plan vet recheck in 3 days to assess nasal d/c consider echo to evaluate heart Prognosis: good with care SURGERY: Permanent waiver due to heart murmur and advanced age
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