PHOEBE – A1115321

PHOEBE – A1115321

FEMALE, BROWN, COCKER SPAN MIX, 10 yrs
STRAY – STRAY WAIT, HOLD RELEASED Reason STRAY
Intake condition EXAM REQ Intake Date 06/14/2017, From NY 11436, DueOut Date 06/19/2017,

Medical Behavior Evaluation GREEN
Medical Summary DVM Intake Exam 6/15/17 Estimated age: ~10+yrs, male Microchip noted on Intake? No History : Brought in by NYPD, called by owner due to not being able to care for dog Subjective: Observed Behavior – Depressed, lethargic, allowed all handling  Objective T = 100.2 P = 100 R = 24 BCS 4/9 EENT: Nuclear sclerosis, eyes sunken, mild mucoid discharge, ears clean, no nasal discharge noted Oral Exam: Pale pink moist mm, moderate dental tartar PLN: No enlargements noted H/L: Grade 2/6 heart murmur, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: Male MSI: Laterally recumbent, no injuries, wet foul smelling coat with areas of matting and deep pyoderma, areas of maggot infestations, no deep wounds seen, maggot infestation appears to be superficial CNS: mentation appropriate – no signs of neurologic abnormalities — depressed Assessment: Geriatric, low grade heart murmur, maggot infestation, moist dermatitis, weak, depressed Plan: Administered convenia 0.87ml SQ, hydromorphone 0.22ml IM, 1 capstar tab given; place IVC start LRS at 25ml/hr, CBC/Chem. Shaved off several matts and manually removed maggots with hydrogen peroxide guaze, unable to remove all maggots Prognosis: Fair — depending on underlying condition SURGERY: Permanent waiver due to age and poor condition at this time Addendum: Blood work shows severe renal disease Mild inflammatory leukogram (WBC19.71; NEU 15.42 with bands; MONO 1.59) Moderate non-regenerative anemia (25.8%) Severe azotemia (BUN >130; Creat not given, likely too high to read; Phos >16.1), mild increased ALT (294), decreased calcium, sodium and cloride Low normal TT4, hypothyroid vs euthyroid disease
Weight 19.5

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