MAGGIE – A1114371
Safe - 6-9-2017 Brooklyn
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SAFE 06/09/17
MAGGIE – A1114371
FEMALE, TAN, PEKINGESE MIX, 13 yrs
STRAY – STRAY WAIT, HOLD FOR ID Reason STRAY
Intake condition UNSPECIFIE Intake Date 06/05/2017, From NY 11208, DueOut Date 06/15/2017,
Medical Behavior Evaluation YELLOW
Medical Summary DVM Intake Exam Estimated age: 13 or older Microchip noted on Intake? no History : stray Subjective: this dogs mandible has eroded away from profound dental disease–the lower lip hangs freely and has no hard tissue beneath it Observed Behavior – likes people, allows exam but head shy–may be pain related. will cry and threaten to bite but not follow through Evidence of Trauma seen – yes—neglect Objective P = 60 R = panting BCS 4/9 EENT: OU sclerosis ears wnl Oral Exam: see above. Profound periodontal disease affecting the integrity of the jaw. only a few molars remain with severe disease PLN: No enlargements noted H/L: heart murmur–had to assess over panting but 3/6 at least, holosystolic ABD: Non painful, no masses palpated U/G: one MGT in left caudal gland with ulceration, dime sized. mass is relatively well circumscribed MSI: Ambulatory x 4, skin free of parasites, no masses noted, matted hair coat. Nails greatly overgrown, some nearly 1 inch long CNS: mentation appropriate – no signs of neurologic abnormalities Assessment: MGT, presumed malignant. erosion of mandible from profound periodontal disease, heart murmur Plan: clavamox for dental infection. recc echo before dental or MGT surgery considered. Prognosis: guarded. Although this dog is stable, several severe disease processes are present. workup vs hospice care are both valid choices. SURGERY: Permanent waiver due to age
Weight 12.2
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