JACE – 36438

JACE – 36438

Care Center Location: Manhattan,  ZIP Code From: 10462,  Intake Type: Stray

Medical Behavior: Blue,  Age: 10 years,  Sex:  Male

Weight: 4 lbs

DVM Intake Exam; Estimated age: Estimated 8-12 years based on dentition and overall appearance; Microchip noted on Intake? Scanned neg; History : Stray, no health hx available; Subjective: Alert, energetic, runs around the room; Observed Behavior – Stressed, tense body. Resists restraint but eventually allows all handling. Objective ; BAR-H, MMs pink and moist, BCS 3/9; EENT: Immature cataracts OU. Ears clean, no nasal or ocular discharge noted. Oral Exam: Moderate tartar, gingival recession; PLN: No enlargements noted; H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic; ABD: Soft, non painful, no masses palpated, not distended; U/G: Male intact, testicles S/S; MSI: Skitters around the room. Lifts right hind leg occasionally when walking. Medial patellar luxation – bilaterally grade 2/4. Long nails. Skin free of parasites, no masses noted, healthy hair coat. CNS: Mentation appropriate – no signs of neurologic abnormalities; Rectal: Normal externally; Assessment: 1. Geriatric, underweight 2. Cataracts OU 3. Dental disease 4. Medial patellar luxation 5. Long nails – trimmed during exam; Prognosis: Fair-good; Plan: 1. Trimmed nails 2. CBC/chem; 3. Recommend dental cleaning and daily tooth brushing 4. Monitor for lameness, consider ortho consult for patellar luxation; SURGERY: Permanent waiver due to age.

Vet Notes: 12:51 PM; CBC: Hct 44.6%; WBC 7.87 k/ul; Plt 430 k/ul; Chemistry: Low K – 3.4 mmol/L – R/O spurious; Elevated GGT 13 u/l – R/O mild GI upset or mild cholestasis; Low cholesterol 96 mg/dl – R/O spurious; No other abnormalities – glucose 81, BUN 12, creat 0.7, total protein 6.5, alb 3.0; ASSESSMENT: No significant values. Recommend repeating bloodwork in 3-6 months.

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