PRINCESS LIMA BEAN – 23241
Safe - 3-28-2018 Manhattan
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PRINCESS LIMA BEAN – 23241
Intake Date : 3/19/18 Intake Type: Stray
Medical Behavior: Yellow Age: 5 years Sex: Female
Weight: 52 lbs
DVM Intake Exam : Estimated age: 3-8 years based on dentition and overall impression Microchip noted on Intake? Scanned negative – MC placed History : No health hx available Subjective: Alert, whining when unattended Observed Behavior – Tense, nervous, jumps around occasionally but allows all handling. Muzzled for safety. Evidence of Cruelty seen – None Evidence of Trauma seen – None Objective : BAR-H, MMs pink and moist, BCS 5/9 EENT: AU mild yellow discharge, mild lichenification. AD aural hematoma developing in the distal 1/3 of the pinna; pinna is erythematous and warm. Eyes clear, no nasal or ocular discharge noted Oral Exam: Muzzled. Incisors are very clean. PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Soft, non painful, no masses palpated U/G: Female, pendulous nipples, developed vulva. No masses or discharge noted. MSI: Small erythematous alopecic lesions on the medial aspect of pt’s carpi and feet. Mild spotty alopecia on dorsum. Skin free of parasites, no masses noted. CNS: Mentation appropriate – no signs of neurologic abnormalities Rectal: Normal externally Assessment: 1. Otitis externa with small aural hematoma AD 2. Lesions on pt’s feet – R/O traumatic/related to sleeping on rough surfaces Prognosis: Good Plan: 1. Cleaned ears and administered Osurnia AU – repeat in 7 days 2. Rimadyl 100 mg PO SID x5 days SURGERY: Okay for surgery
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