PEACHES – 33453
Safe - 7-7-2018 Brooklyn
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PEACHES – 33453
Location: Brooklyn; Intake Date: 7/6/18; Intake Type: Owner Surrender; Medical
Behavior: Blue; Sex: Female; Age: 10 years; Weight: 19 lbs; Original Location: 11208
DVM Intake Exam; Estimated age:10y Microchip noted on Intake?yes Microchip Number (If Applicable):981010001939604. History :owner surrender Subjective:bar Observed Behavior – Objective T = P = 120 R = wnl BCS 3/5. EENT: Eyes clear, chronic otitis au/thickened ear canals, mild yellow debris, no nasal or ocular discharge noted, os mid ventral lid 2-3 mm eyelid mass Oral Exam: mod dental tarter PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated UG: intact (prominent vulva), many varying-sized mgt’s bilaterally mid ventral caudal MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat, overgrown nails CNS: Mentation appropriate – no signs of neurologic abnormalities Rectal:ne Assessment: 10 yr fi small mixed breed 1)mgt’s – r/o benign (primary vs secondary to being older, intact) vs malignant 2)dental tarter 3)eyelid mass – r/o meibomian gland mass vs other benign or malignant 4) chronic otitis. Prognosis: good to excellent for mgt’s and eyelid mass w/ sx and ovh. good for chronic ear with maintenance cleaning and monitoring Plan: 1)clean ears and mometamax sid x 14 days, recheck in 14 days 2)rec ovh and mgt removal with histopathology 3)rec removal eyelid mass and full dental care SURGERY: Temporary waiver due to age
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