KELEE – 34396

KELEE – 34396

Location: Brooklyn; Intake Date: 7/14/18; Intake Type: Stray Medical Behavior:

Green; Sex: Female; Age: 12 years; Weight: 7 lbs; Original Location: 11205

Vet Notes: 12:43 PM – DVM Intake Exam:  Estimated age: 12 years Microchip noted on Intake? positive 103830561 History : Agency Subjective: QARH Observed Behavior – very sweet. Easily handleable. Did well for all medical handling and procedures. Objective: P = wnl  R = eupneic BCS 4/9 EENT: Eyes sealed with thick purulent d/c, unable to assess globes due to thick mucoid d/c and chemosis, ears clean, no nasal discharge noted Oral Exam: adult dentition with severe dental disease, oligdontia, and prognathism, no oral lesions noted PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic ABD: Non painful, no masses palpated U/G: FI, ulcerated ~3cm ruptured MGT on cranial mammary chain in between the two sides with purulent d/c, no vulvar d/c MSI: Ambulatory x 4, skin free of parasites,unkempt hair coat CNS: mentation appropriate – no signs of neurologic abnormalities. Assessment: Geriatric-suspect underlying. Severe conjunctivitis. Ruptured MGT. Severe dental disease Plan: Continue to monitor while at BACC CBC pending Chem pending STT OS-17 @ 15s, OD-0 @ 60s Fluorescein stain pending Cleaned eyes and shaved matts off face Scheduled 3 view CXR tomorrow Cleaned ulcerated MGT with dilute chlorhex Start clavamox 13.75mg/kg PO BID x7d until 7/22 Start erythromycin OU BID x7d until 7/22, recheck Start optimmune OU BID indefinitely Rec biopsy +/- surgical removal of MGT Rec ophthalmology consult for chronic eye condition. Prognosis: Poor to guarded SURGERY: permanent waiver due to age and MGT

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