SPARKY – 33776
Safe - 7-9-2018 Brooklyn
SPARKY – 33776
Care Center Location: Brooklyn, ZIP Code From: 10458, Intake Type: Owner surrender
Medical Behavior: Blue, Age: 24 years, Sex: Spayed female
DVM Intake Exam; Estimated age: o reports 24, appears markedly geriatric by exam; Microchip noted on Intake? neg; History : o surrender – elder mother unable to care for dog; Subjective: QAR. Marked dehydration, very thin. Eats well. Observed Behavior – Quiet, allows handling but trying to nip with vx, blood draw; Objective ; T =; P =150; R = eup; BCS = 2/6; EENT: Eyes – OD sunken in, OS cornea clouded over, unable to see pupils, no menance. Ears clean, no nasal or ocular discharge noted; Oral Exam: lower canines and R upper canine and few other caudal teeth present but severe periodontal dz and calculus. PLN: No enlargements noted; H/L: 2/6 murmur, NSR, CRT < 2, Lungs clear bilat, eupnic; ABD: Non painful, no masses palpated; U/G: FS – o reports spayed, no MGT’s; MSI: Ambulatory x 4 but weak, skin free of parasites, no masses noted, healthy hair coat, cachectic, muscle wasting. Mod dehydration. CNS: Mentation appropriate – no signs of neurologic abnormalities; Rectal: Assessment: 1. Very geriatric F Terrier x; 2. Heart murmur; 3. Blind; 4. Enopthalmos OD; 5. Marked dental dz. Prognosis: Guarded; Plan: CBC/ Chem/ lytes/ T4; CBC- mild anemia; Chem- marked inc BUN and phosphorus but CR high normal. Still suspect renal dz but need UA SpGr to confirm. T4/ Lytes – WNL. Assessment: r/o renal failure; Prognosis: Guarded- poor. Need serial future BW to confirm prognosis. Recom rescue/ hospice care
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