HEAVEN – A1119249

Manhattan Center

My name is HEAVEN. My Animal ID # is A1119249.
I am a female cream shih tzu mix. The shelter thinks I am about 8 YEARS old.

I came in the shelter as a STRAY on 07/21/2017 from NY 10040, owner surrender reason stated was STRAY.

07/24/2017 AT RISK MEMO
A1119249 Heaven is At Risk for medical reasons (please see exam below)

MOST RECENT MEDICAL INFORMATION AND WEIGHT
07/23/2017 Exam Type VACCINATE – Medical Rating is 4 NC – SEVERE CONDITIONS NOT CONTAGIOUS, Behavior Rating is NONE, Weight 14.8 LBS.

Hx: severely matted on intake; mammary gland tumor S/O good appetite BAR, friendly, allows handling mm pk, moist; underbite, moderate tartar OU-corneas appear dull with pigmentation and severe mucoid discharge no nasal discharge ears clean heart/lungs WNL grapefruit sized, multi-lobulated mammary tumor on L chain recently shaved-was previously severely matted 2 small sebaceous adenomas over dorsum-cranial one has mild irritation possibly from shavedown BCS 4/9 A Mammary tumor KCS-suspected P unable to perform STT at this time due to lack of test strip, rec’d adding optimmune OU BID and rechecking STT once available/monitoring clinical response rec’d excisional biopsy of MGT prognosis: open, depends on histopath of MGT

07/21/2017 PET PROFILE MEMO
07/21/17 14:07 Heaven allowed all handling, being collared, having her picture taken, being picked up and being petted as well.

WEB MEMO
No Web Memo

07/23/2017 BEHAVIOR EVALUATION – EXPERIENCE
Exam Type BEHAVIOR
KNOWN HISTORY: None 07/21/17 Intact female, stray SAFER ASSESSMENT: 07/23/17 Look: 1. Dog’s eyes are averted. Her ears are back, her tail is down, and she has a relaxed body posture. Dog allows head to be held loosely in Assessor’s cupped hands. Sensitivity: 3. Dog is not fearful and is struggling to get away. The dog is not focused and is in constant movement, unconnected to the Assessor Tag: 1. Follows at end of leash, body a bit fearful Squeeze 1 & 2: 2. Dog quickly pulls back. Toy: 1. No interest Summary: Heaven tolerated all handling throughout her assessment, she was a bit fearful at times though. INTAKE BEHAVIOR 07/21/17 Upon intake, Heaven allowed all handling. MEDICAL BEHAVIOR: 07/22/17 During her initial medical examination, Heaven allowed all handling. ENERGY LEVEL: Heaven displays a low energy level in the care center. RECOMMENDATIONS: Experience (Suitable for an adopter with a previous amount of dog experience) Potential challenges: _X_Fearful: Though observed to be human-social, Heaven may need time to warm up to the handler as she initially presents as a fearful dog, avoiding contact, shying away from direct touch. We recommend allowing Heaven to interact at her own pace, force-free, rewarding based training is advised when introducing her to new/unfamiliar situations.

GROUP BEHAVIOR EVALUATION 
No Group Behavior Summary

07/22/2017 DVM INTAKE PHYSICAL EXAM
Medical rating was 3 NC – MAJOR CONDITIONS NOT CONTAGIOUS, behavior rating was NONE
07/22/17 09:46 S/O: BAR, shaved, eaten good energy, amb x4 M/S: amb x4, BCS 5/9 EENT: corneal scarring OU, moderate purulent d/c UROGEN: large tumor with small area of ulceration on ventral surface appears to be associated with mammary chain NEURO: NSF H/L: NSF SKIN: small sebaceous gland adenoma on dorsal lumbar area A: previously matted- Cruelty case corneal scarring with infection: r/o underlying KCS mass: r/o benign vs. malignant P: add on simplicef 100mg: 1/2T PO SID x14 rec check STT- scheduled 7/21/17 DVM Intake Exam Estimated age: Microchip noted on Intake? neg History : flagged for cruelty, found in park as per person that brought p in Subjective: Observed Behavior – gentle, allows all handling Evidence of Cruelty seen – YES Evidence of Trauma seen – no Objective P = 120 R = pant, but eupneic BCS 5/9 EENT: under mats, able to locate one eye- OS- intact, with mild purulent d/c, mat so thick couldn’t locate right eye, ears clean, no nasal discharge noted Oral Exam: mild tartar and gingivitis PLN: could not palpate through severe mats H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: female, could not fully examine d/t severe mats- large firm, no npainful approx 12cm mass which appears to be associated with L side of mammary chain present MSI: Ambulatory x 4, SEVERE MATTING all over, including dorsal aspects of paws and pinnae, face was so severely matted no eyes were visible- had to gently pry space open to be able to find left eye which has mild purulent d/c CNS: mentation appropriate – no signs of neurologic abnormalities Assessment HIGH SUSPECT CRUELTY severe matting mass: suspected to be mammary in nature visible eye- OS- bacterial infection: r/o secondary to constant contact with fur, other Plan needs to be shaved down, clippings to be saved alerted cruelty group about p TAB ointment OU BID x7 rec re- exam once shaved for more comprehensive exam- limited because of severe matting OS apperas to have bacterial infection- will re assess other eye once shaved down mass: r/o benign vs. malignant Prognosis: open SURGERY: permanent waiver d/t crulety flag and suspected mammary mass

No RE-EXAM or CAGE-EXAM found
– Normal,
No detailed description for a visit type RE-EXAM or CAGE-EXAM found!

 

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