PHOENIX – A1118024
Safe - 7-13-2017 Staten Island
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SAFE 07/13/17
PHOENIX – A1118024
NEUTERED MALE, BLACK / TAN, YORKSHIRE TERR MIX, 12 yrs
STRAY – PLACED, NO HOLD Reason STRAY
Intake condition GERIATRIC Intake Date 07/10/2017, From NY 11236, DueOut Date 07/13/2017,
Medical Behavior Evaluation GREEN
Medical Summary DVM Intake Exam 7/11/17 Estimated age:~12+ yrs Microchip noted on Intake? No History : Stray Subjective: Observed Behavior – QAR. Allows all handling. Eating with excellent appetite Objective P = WNL R = WNL BCS 3/9 EENT: Nuclear sclerosis OU with mucoid film, ears clean, no nasal discharge noted Oral Exam: Severe dental tartar/gingivitis, gingival recession at molars with tooth root exposure, ruptured abscess near right ramus of mandible, thin purulent discharge, two small skin wounds PLN: Significant enlargement of submandibular LN (R>L) H/L: Pale mm, grade 5/6 left systolic heart murmur, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated — soft, distended U/G: Neutered MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat; bilateral grade 4/4 MPL CNS: mentation appropriate – no signs of neurologic abnormalities Assessment: Geriatric, heart murmur, KCS, severe dental disease with possible tooth root abscess, MPL Plan: Rec augmentin 1ml PO q12 x 14 days. CBC/Chem pending. Rec full cardiology work up with placement, dental pending results Rabies, da2pp, bordatella, effipro, pyrantel, MC, HWT done Prognosis: Poor Addendum: blood work results Moderate leukocystosis (25.26%) characterized by a moderate neutrophilia (16.02K/uL) with bands suspected, mild monocytosis (2.95K/uL) and lymphocytosis (6.21K/uL) ; marked non-regenerative anemia (15.5%) Mild decreases in albumin (2.1g/dL) and calcium (7/6mg/dL), mild increases in ALKP (383U/L) and globulins (4.8g/dL). Mild decreased TT4 0.7ug/dL Assessment: Inflammatory leukogram, marked anemia. Very mild chemistry changes. Rule out hypothyroid vs euthyroid sick disease — consider freeT4, canine TSH with placement
Weight 6.0
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