LADY – 24337

LADY – 24337

Care Center Location: Manhattan,  ZIP Code From: 10473,  Intake Type: Owner surrender

Medical Behavior: Blue,  Age: 11 years,  Sex: Spayed female,  Weight: 16 lbs

DVM Intake Exam; Estimated age: Reported 11 years – exam is consistent with this; Microchip noted on Intake? Scanned POSITIVE on intake; History : Pt has an eye infection that was diagnosed in August 2017 – prescribed neomycin eye medication. Client did not go back and stopped the medication when it ran out. No other health issues reported.; Subjective: Alert, is carried easily, sits still for exam; Observed Behavior – Slightly tense, closes eyes during exam. Does not resist.; Objective ; BAR-H, MMs pink and moist, BCS 8/9; EENT: OD moderate conjunctival erythema and mucoid discharge, clean cornea. OS moderate conjunctival erythema and mucoid discharge, central corneal opacity. Ears clean, no nasal or ocular discharge noted; Oral Exam: Moderate tartar, halitosis; PLN: No enlargements noted; H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic; ABD: Soft, non painful, no masses palpated; U/G: Female, small nipples and vulva, spay scar visible on ventrum; MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat; CNS: Mentation appropriate – no signs of neurologic abnormalities; Rectal: Normal externally; Fluorescein stain to eyes – no uptake OU; Assessment: 1. Ocular changes – suspect KCS vs. glaucoma. No corneal ulceration. 2. Obese; 3. Dental disease; 4. Geriatric; Prognosis: Fair; Plan: 1. Schirmer tear test tomorrow; 2. Recommend weight loss of 3-6 lbs 3. Recommend dental cleaning and daily tooth brushing 4. CBC/chemistry

 

CAME IN WITH CAT

Baby 24336  http://nyccats.urgentpodr.org/baby-24336/

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