MAX – A1125579
Safe - 9-22-2017 Manhattan
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SAFE 09/22/17
MAX – A1125579
NEUTERED MALE, TAN / WHITE, CHIHUAHUA SH MIX, 10 yrs
OWNER SUR – ONHOLDAVAI, HOLD FOR ID Reason LLORDNYCHA
Intake condition EXAM REQ Intake Date 09/15/2017, From NY 10009, DueOut Date 09/15/2017, I came in with Group/Litter #K17-111498.
Medical Behavior Evaluation BLUE
Medical Summary DVM Intake Exam Estimated age: neutered male 10 yo Microchip noted on Intake? positive scan – in record History : o surrender 2 dogs – not allowed in housing Subjective: BARH. Observed Behavior – Vocal. Muzzled but allows all handling. Objective T = P = 120 R = 30 BCS=7/9 EENT: Eyes – marked lenticular changes OU, PLR decreased and incomplete, no discharges, conj/ cornea/ sclera clr. Moderate cherry eye OS. Ears – slightly dirty AS > AD. No nasal discharge noted. Oral Exam: marked tartar covering molars, mod gingivitis, halitosis – full exam not done since muzzled. NSF noted after removing muzzle but unable to do full exam. PLN: No enlargements noted. H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: neutered male MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat. Obese. CNS: mentation appropriate – no signs of neurologic abnormalities Rectal: not done. Assessment: 10 yo neutered male Chi. 2.. Cherry eye OS. 3. Dental dz. 4. Obese. 5. Inspiratory increased BVS and effort – r/o due to obesity 6. Decreased vision Plan: Dental prophylaxis recommended but caution due to resp issues. Recom lose wt (3+ lbs) and re-assess lungs after – in 2-4 mos – prior to anesthesia. If still has increased breathing effort, consider xrays. Consider cherry eye sx at same time as dental. Cleaned ears. Prognosis: Fair to good.
Weight 22.0
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