STAR – A1108957
Safe - 4-20-2017 Manhattan
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SAFE 04/20/17
STAR – A1108957
FEMALE, WHITE, MALTESE / POODLE MIN, 13 yrs
OWNER SUR – AVAILABLE, NO HOLD Reason PET HEALTH
Intake condition GERIATRIC Intake Date 04/15/2017, From NY 10033, DueOut Date 04/15/2017,
Medical Behavior Evaluation YELLOW
Medical Summary DVM Intake Exam Estimated age:13 yo Microchip noted on Intake No History Chronic bilareal eye infection (swollen) Subjective: 13 yo IF Observed Behavior – Does not like to handle, shows aggression when manipulation for the ears Evidence of Cruelty seen – No Evidence of Trauma seen – No Objective T = WNL P = 140 R = Pnating BCS 5/9 EENT: OD microphtalmia and prolasped gland (cherry eye), OS clear, ears swollen and yellow discahrge, no nasal discharge noted Oral Exam: Severe periodontal diasease grade 3-4 PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: Intact female MSI: Ambulatory x 4, skin free of parasites, no masses noted, severely matted hair CNS: mentation appropriate – no signs of neurologic abnormalities Rectal: Not performed Assessment – Geraitic pet – Severe bilateral chronic ear infection (both ear canlas are closed) – Severe periodontal disease – Severe mattes hair Plan – Wt: 12.75 lb – HWT snap test (negative) – Vaccines (DAPP SQ RFL; Bordetella IN; Rabies SQ RHL) – Dewormed (Pyrantel) – Flea prevention treatment – Microchip place (Between shoulder blades):981020019748613 Recommmend full grooming Recommend NH placement of EHR Prognosis: Fair to Good If treated (chronic ear infection) Recommmend Ear and eye surgeries, dental prophylaxis, Permanent waiver due to Geriatric dog
Weight 12.8
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