LUCY – 18666

LUCY – 18666

*NEEDS ENUCLEATION*

Small Tan and White Mix, Stray 01/19/18

DVM Intake Exam; Estimated age: 8-10; Microchip noted on Intake? None History : Stray; Subjective: BARH; Observed Behavior – Easily handleable for exam but did not like being restrained around her head; Evidence of Trauma seen – Yes Objective ; T =; P = 96; R = eup; BCS= 5/9; EENT: Eyes – OS partially proptosed and crusted over, not visual. OD – bupthalmic, mod nuclear sclerosis, PLR +, no discharge, sclera and conj clr, corneal pigmentation medial globe. Ears clean. No nasal discharge noted; Oral Exam: Marked calculus. PLN: No enlargements noted; H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic; ABD: Non painful, no masses palpated; U/G: Female – no spay scar seen. Vulva prominent, no discharge; MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat. Well groomed.  CNS: Mentation appropriate – no signs of neurologic abnormalities; Rectal: Assessment:  Partially proptosed left eye – crusted over – r/o trauma – likely happened more 5-7 days prior; Prognosis: Guarded; Plan:  Needs rescue and enucleation left eye and full ophthalmic exam right eye (r/o KCS, glaucoma). Tramadol 50 mg 1/4 tab po bid but appears comfortable.  SURGERY: Permanent waiver due to geriatric age and medical condition.

Let’s get to know each other a bit more…

Date of Intake:  19-Jan-2018

Basic Information:
Lucy ” 18666″ is a possible stray dog that was found around 10 this morning. The client found Lucy walking across the street from her home. Lucy appear alert and active. Lucy was found with a possible inflamed eyeball.

Previously lived with:  found stray
How is this dog around strangers?  Lucy was relaxed and friendly with the staff members. She allowed to be touched and picked up.
How is this dog around children?  Unknown
How is this dog around other dogs?  Unknown
How is this dog around cats?  Unknown

Medical Notes:  Lucy has an inflamed eyeball. The eyeball appears to be swollen and infected.

Behavior Notes:Upon intake Lucy was relaxed and friendly. She allowed all handling. Scanned negative. Lucy was found with a light blue collar.

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