MADONNA – 26817
Safe -
5-10-2018 Manhattan
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SAFE 05/10/18
MADONNA – 26817
Care Center Location: Manhattan, ZIP Code From: 10029,
Intake Type: Stray, Medical Behavior: Blue, Age: 10 years, Sex: Female
Weight: 10 lbs
DVM Intake Exam; Estimated age: 8-14 years based on dentition and cataracts; Microchip noted on Intake? Scanned negative – MC placed during LVT exam; History : Stray, no health hx available; Subjective: Alert, walks on leash, coughs when standing still on tethered leash; Observed Behavior – Allows all handling. Slightly tense at times. Objective ; BAR-H, MMs pale pink and moist, BCS 7/9; EENT: Immature cataracts OU. Mild mucoid ocular discharge OU. Clean ears, no nasal discharge noted. Oral Exam: Some missing teeth. Remaining teeth have mild-moderate tartar; PLN: No enlargements noted; H/L: Grade 5/6 systolic heart murmur with thrill, PMI left side of the heart. NSR. CRT < 2, Regular wheezy cough when standing on the ground (not when being held). Lungs clear, eupnic. ABD: Soft, not distended, non painful, no masses palpated; U/G: Female, no spay scar palpated; 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; Assessment: 1. Heart murmur; 2. Cough – R/O heart disease vs. collapsing trachea vs. other; 3. Overweight; 4. Dental disease; 5. Cataracts; Prognosis: Fair; Plan: 1. Recommend chest rads to evaluate for cardiomegaly and collapsing trachea; 2. Recommend daily tooth brushing and regular dental cleanings; 3. Recommend weight loss of approx 2 lbs; SURGERY: Permanent waiver due to heart murmur and age (geriatric)
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