RAISIN – A1113041
Safe - 5-25-2017 Manhattan
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SAFE 05/25/17
RAISIN – A1113041
MALE, TAN, DACHSHUND MIX, 10 yrs
STRAY – STRAYAVAI, NO HOLD Reason STRAY
Intake condition EXAM REQ Intake Date 05/24/2017, From NY 10009, DueOut Date 05/27/2017,
Medical Behavior Evaluation GREEN
Medical Summary Estimated age: 10-12 years Microchip noted on Intake? neg. Stray, BAR Observed Behavior – docile, wags tail; allows handling BCS 4/9 EENT: Eyes clear, ears clean, no nasal discharge noted Oral Exam: resists oral exam; tongue hangs out of front of mouth; drooling; severe dental disease-most teeth missing; upper premolars appear black; severe halitosis; mild swelling around mouth and bilateral firm swelling under eyes-suspect tooth root abscess; poss abnormality of mandible PLN: No enlargements noted H/L: no murmurs or arrhythmias; eupnic, normal lung sounds; SSFP ABD: Non painful, no masses palpated U/G: male neutered MSI: ambulatory x 4 mild thickening of stifles bilaterally with some discomfort on extension of L stifle mild kyphosis of TL spine with discomfort on palpation of T13/L1 CNS: mentation appropriate – no signs of neurologic abnormalities Rectal: Assessment Facial swelling-r/o tooth root abscess vs neoplasia vs other Severe periodontal dz, halitosis back pain-r/o IVDD vs other Plan clindamycin BID x 14 days tramadol 1/4 tab BID x 10 days rimadyl 12.5 mg SID x 4 days Rec’d CBC/chem Rec’d dental with dental radiographs and extractions of all remaining teeth ASAP Prognosis: fair to good SURGERY: neutered
Weight 10.9
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