MIKA – A1119017
Safe - 7-25-2017 Manhattan
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MIKA – A1119017
SPAYED FEMALE, WHITE / BLACK, YORKSHIRE TERR / SHIH TZU, 7 yrs
OWNER SUR – EVALUATE, NO HOLD Reason OWN EVICT
Intake condition EXAM REQ Intake Date 07/19/2017, From NY 10458, DueOut Date 07/19/2017,
Medical Behavior Evaluation BLUE
Medical Summary DVM Intake Exam Estimated age: 7 yo Microchip noted on Intake? n History : owner surrender Subjective: Cherry eye OS, overgrown nails and haircoat with some knots Observed Behavior – interacts well, ok with being picked up and handled Objective P = 120 R = 20 BCS 5/9 EENT: Mild cherry eye OS, eyes otherwise clear, ears clean, no nasal discharge noted Oral Exam: pink mm w/ CRT < 2s, heavy calculus over premolars 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 noted MSI: Ambulatory x 4, multilobulated skin tumor at ventral base of tail- painful to the touch, skin free of parasites, overgrown hair with knots CNS: mentation appropriate – no signs of neurologic abnormalities Assessment: 1. Cherry eye- no treatment needed 2. Skin mass ventral base of tail, painful- cyst vs abcess vs neoplasia Plan: Ok for surgery – clip hair around tailbase under anesthesia and check for abcess and/or consider mass removal/biopsy Prognosis: Good SURGERY: Okay for surgery
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