ROMEO SANTOS – 24931

ROMEO SANTOS – 24931

Location: Manhattan,  Intake Date: 4/10/18,  Intake Type: Stray

Medical Behavior: Blue,  Sex: Male,  Age: 10 years,  Weight: — lbs,  Original Location: 10031

DVM Intake Exam; Estimated age:10-12 years; Microchip noted on Intake?  History :dog was found about a week ago in a kennel outside; finder was going to keep him but he has accidents in the home; Subjective:QAR; Observed Behavior -decreased hearing, appears blind, possibly has limited vision; docile and allows handling but resists oral exam; good appetite; Objective ; BCS 4.5/9; EENT:  OU-mostly to fully blind, possibly sees shadows; immature cataracts OU, difficult to visualize retinas through cataracts but can visualize retinal vessels with no obvious areas of hemorrhage; mild serous nasal discharge, soft sneezed during exam; AU: mild inflammation, chronic lichenification, mild yeasty debris, pruritic; Oral Exam:resists ful oral exam; mm pk, sl tacky; CRT <2 sec; underbite, moderate tartar on rostral teeth; PLN: No enlargements noted; H/L: eupnic, clear lung sounds, no murmurs or arrhythmias; ABD: Non painful, no masses palpated; U/G: male intact, 2 scrotal testicles; MSI:  -LF: grade I/IV lameness, decreased elbow extension with some discomfort; -LH: crosses limb occasionally, decreased hip extension with discomfort; mild thickening of stifle with grade II/IV patellar luxation and decreased stifle extension with mild discomfort; -RH: mild to moderately decreased hip extension with some discomfort -mild focal areas or erythema on medial aspect of limbs, suspect mild allergies; -significant discomfort on TL palpation CNS: Mentation appropriate; high stepping gait; normal proprioception x 4, normal-increased withdrawal; Rectal:grossly normal; Assessment; 1. Geriatric; 2. Blind-do not suspect secondary to immature cataracts, r/o retinopathy vs neurologic vs other; 3. LF lameness, suspect mild elbow arthritis; 4. Decreased hip extension bilaterally; 5. LH lameness-r/o hip arthritis vs mild CCL injury and/or stifle arthritis vs patellar luxation vs secondary to back pain; 6. TL discomfort-r/o chronic IVDD vs other; 7. Otitis externa; Prognosis:fair; Plan: -gentizol AU SID x 7 days -gabapentin 50 mg/ml: 1/2 ml PO BID x 7 days, consider continuing long term if provides adequate pain control without pronounced sedative effect -CBC/chem; SURGERY:permanent waiver due to age

Behavior Notes:
Romeo Santos allowed all handling upon intake. He allowed being collared and although he was tumbling to the side he attempted to pose nicely for a picture. He was receptive to head and body touches and also allowed being lifted. He was a little shy when first approached but quickly came around and began to wander around and become more comfortable.

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