TRINA – A1126800

TRINA – A1126800

FEMALE, WHITE / BROWN, SHIH TZU MIX, 10 yrs
OWNER SUR – WAITING4PU, NO HOLD Reason NEW BABY
Intake condition GERIATRIC Intake Date 09/27/2017, From NY 10471, DueOut Date 09/27/2017,

Medical Behavior Evaluation GREEN
Medical Summary DVM Intake Exam Estimated age: reported to be 10 years Microchip noted on Intake? History : owner surrender because owner just had a baby and is unable to care for dog financially Subjective: BAR Observed Behavior – docile, friendly; allows all handling  BCS 5/9 EENT: Eyes clear, ears clean, no nasal discharge noted Oral Exam: mm pk, tacky; CRT <2 sec; severe underbite, dental disease; missing upper incisors with gingival hyperplasia/growths along gumline PLN: submandibular LN prominent H/L: intermittent gallop arrhythmia with possible grade II focal L sided murmur; eupnic, lungs clear ABD: Non painful, no masses palpated U/G:female intact; pedunculated, lobulated mass protruding from vulvular mucous membrane MSI: Ambulatory x 4, skin free of parasites, small fluctuant SQ lump on top of head near ear base AD CNS: mentation appropriate – no signs of neurologic abnormalities Rectal: not performed, appears grossly normal Assessment Vulvular mass Dental disease with underbite and gingivial hyperplasia Geriatric Arrythmia/poss heart murmur Plan Rec’d cardiac evaluation including at least ECG and CXR but ideally with full echocardiogram Rec’d excision of vulvular mass and dental cleaning with likely extractions and possible biopsy of gingiva Prognosis: open, depends on histopath of vulvular mass SURGERY: permanent waiver due to age
Weight 7.9

 

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