SUNSHINE – 12225
Safe - 11-15-2017 Manhattan
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SAFE 11/15/17
SUNSHINE – 12225
Location: Manhattan; Intake Date: 11/10/17; Intake Type: Stray
Medical Behavior: Green; Sex: Female; Age: 10 years; Weight: — lbs
DVM Intake Exam: Estimated age: +/-10. Microchip noted on Intake? No History : Stray from 96th and 1st Mcdonalds. Subjective: BAR Hydr wnl Observed Behavior – Really nice dog, appears to be used to dvm exam. Objective: T = 101.4 P = 144 R = wnl. BCS 6/9 EENT: Eyes clear, no nasal or ocular discharge noted AU mild malodor and yellow brown debris. Oral Exam: mild tartar, moderate to severe gingival recession incisors PLN: No enlargements noted H/L: NSR, 2/6 hm, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: pigmented mod enlarged vulva, n obv mgt palpated MSI: Bilat mpl w/o decreased range of motion hips, Ambulatory x 4 without obv gait deficit, skin free of parasites, no masses noted, healthy hair coat, vulva extending to ventral abd hyperigmentation CNS: Mentation appropriate – no signs of neurologic abnormalities Assessment: HM r/o mr/tr, clinical significance melanosis r/o endocrine, chronic skin dz, other bilat mpl decreased range of motion hips r/o dysplasia, other otitis r/o allergies, conformation, other Prognosis: guarded to excellent. Plan: Cleaned ears. Tresaderm 6 drops au bid for 10 days
SURGERY: Permanent waiver due to heart murmur
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