JACKIE – A1113979
Safe - 6-4-2017 Manhattan
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SAFE 06/04/17
JACKIE – A1113979
SPAYED FEMALE, WHITE / BLACK, JACK RUSS TERR MIX, 17 yrs
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition EXAM REQ Intake Date 06/02/2017, From NY 10469, DueOut Date 06/05/2017,
Medical Behavior Evaluation BLUE
Medical Summary Estimated age: Reported to be 17 years old – exam is consistent with this Microchip noted on Intake? Scanned POSITIVE on exam. No medical hx given. Timid, shaking, tense. Allows most handling but seems tense. Restrained gently with a towel for vaccines and blood draw. BCS 4/9, MMs pink EENT: Eyes cloudy – nuclear sclerosis or cataracts. Mild brown waxy debris AU. No nasal discharge noted. Oral Exam: Severe tartar accumulation, halitosis – missing some teeth, others are pointing in abnormal angles. H/L: Grade 3/6 systolic heart murmur, PMI left base. NSR. Lungs clear, eupnic ABD: Tucked up, tense. No masses palpated. U/G: Female, reported spayed. Small undeveloped nipples and vulva. Two small semifirm masses associated with the left and right caudal mammary glands (2nd to last set). MSI: Hind legs are trembling throughout exam. Decreased muscle mass in hind limbs. No crepitus noted in stifles, fair range of motion in both stifles and both hips. Two soft pedunculated masses hanging from the left front leg at the level of the mid-antebrachium. The masses are primarily pink but also have dark pigmented regions. They are soft and hang about 5 cm long. Long toenails, especially on front feet, especially digits 3nd 4 on the right front foot. Skin slightly erythematous especially at dorsal neck. CNS: Quiet, passive. Mentation appropriate – no signs of neurologic abnormalities Assessment 1. Severe dental disease 2. Soft tissue masses on left front leg 3. Small mammary nodules 4. Heart murmur 5. Trembling – R/O discomfort from standing, stress, muscle disease, other Plan 1. Recommend chest rads and possibly echocardiogram – cardiac meds may be indicated 2. If anesthetically safe, consider dental cleaning and extractions of many teeth – pt will likely be much happier once this source of pain is gone 3. Consider FNAs of mammary masses and pedunculated masses on LFL 4. CBC/chemistry Prognosis: Fair 1088
Weight 13.9
A volunteer writes:
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