PENELOPE – 20661
Safe -4-6-2018 Manhattan
PENELOPE – 20661
*NEEDS IMMEDIATE VET CARE *
5Y Black / White S Small Mixed Breed 7 lbs. Owner Surrender: 2/13/18
DVM Intake Exam; Estimated age:Reportedly 5 years; age consistent with 3-5 years; Microchip noted on Intake? yes History :owner surrender; owner originally gave her to a different women in October 2017 but then reclaimed her from that women in December 2017; when owner got her back, she said that Penelope was overnight and more lethargic; since then, Penelope has declined and does not want to eat, drink or move around a lot; no specific medical history available; Subjective:QAR, friendly and docile but appears lethargic, prefers to lie down; Objective ; BCS 4/9; EENT: -OS: mild mucoid nasal discharge, mild episcleral injection, cornea appears slightly dull -OD: open and clear -no nasal discharge or sneezing; Oral Exam:mm pk, tacky; CRT 2 sec; mild hypersalivation; adult dentitia with minimal staining and mild tartar; PLN: No enlargements noted; H/L: eupnic, clear lungs, no murmurs or arrhyhthmias; ABD: soft, nonpainful, slightly doughy, no palpable abnormalitites; U/G: female intact; MSI: -ambulatory x 4 but prefers to lie down -LH, mild adduction at hip but good ROM at joints with no discomfort -clean coat; CNS: -mentation appropriate but lethargic; -absent withdrawal x 4; -present but slightly slow placing on forelimbs; -resistant to turn neck to L but no obvious discomfort on palpation; Rectal:grossly normal; Assessment; 1. Dehydration, dull; 2. Underweight; 3. Absent withdrawal, decreased proprioception-r/o primary neuro (IVDD vs other) vs secondary to dehydration/systemic dz; Prognosis:open; Plan: -CBC/chem -IVC, LRS at 15 ml/hr -spinal radiographs, STT -further treatment pending bw, rads
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