WINTER – 17099

WINTER – 17099

Location: Brooklyn; Intake Date: 12/28/17; Intake Type: Stray

Medical Behavior:  Green; Sex: Male; Age: 12 Years; Weight: 21 lbs; Original Location: 11374

Vet Notes: 2:22 PM:  DVM Intake Exam. Estimated age: ~12-14 years Microchip noted on Intake? negative History : stray  Subjective: BARH. Observed Behavior – very sweet. Easily handleable. Did well for all medical handling and procedures Objective:  P = wnl  R = eupneic  BCS 5/9 EENT: nuclear sclerosis ou with no ocular d/c, ears clean with hair in canals AU, no nasal discharge noted Oral Exam: adult dentition with severe dental disease, no oral lesions noted PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupneicABD: Non painful, no masses palpated U/G: MI, 2 testicles descended
MSI: Ambulatory x 4, grade 2/4 luxating patella on the right, skin free of parasites, no masses noted, thinning and dirty hair coat CNS: mentation appropriate – no signs of neurologic abnormalities, positive menace. Assessment:  Geriatric. Severe dental disease
Nuclear sclerosis ou. Grade 2/4 luxating patella on the right  Thinning haircoat r/o unkempt vs endocrine vs other. Plan: Continue to monitor while at BACC. Rec geriatric workup with placement. Signed up for bath tomorrow. Prognosis: good  SURGERY: permanent waiver due to age

A Little Bit About Me…

 

Let’s get to know each other a bit more…

Basic Information:

Winter is a small stray dog that is possibly 12 year old. The dog was found in front of an apartment building. Finder noticed that dog alone in the cold. Finder decided to bring the dog to ACC.

My medical notes are…

Vet Notes: 11:14 AM: Progress exam (housed in medical) S/O: QARH. Allows all handling. No appetite overnight or early this AM.  EENT: Immature cataracts OU with nuclear sclerosis, no ocular discharge, Minimal nasal discharge, severe dental disease – significant gingival recession and tartar buildup of upper canines. Ears WNL. HL: normal thoracic auscultation. INTEG: Thinning hair coat, mild bruising in region where MC was placed   UG: Intact male — soft and small testicles (left smaller than right)  A: Geriatric
severe dental disease with nasal discharge – R/O tooth root abscesses vs other
Bruising – R/O blood/coag disorder P: Scheduled for blood work. Currently receiving clavamox 125mg PO q12 x 10 days. Providing 0.6 ml gabapentin (50mg/ml) po q24for 7 days as well.  Rec skull rads/dental with placement

Vet Notes: 1:26 PM:  S/O: QARH. Allows all handling.  EENT: Immature cataract OU, no ocular discharge, Profuse mucoid nasal discharge with scan amount of blood, severe dental disease – significant gingival recession and tartar buildup of upper canines. Ears WNL
HL: normal thoracic auscultation INTEG: Thinning hair coat, mild bruising in region where MC was placed  UG: Male A: Geriatric severe dental disease with nasal discharge – R/O tooth root abscesses vs other Bruising – R/O blood/coag disorder. P: Scheduled for blood work. Rec clavamox 125mg PO q12 x 10 days. Rec skull rads/dental with placement

Progress exam
History : stray intake 12/28. On 12/29 had bloody nasal d/c-suspect either CIRDC or tooth root abscess. Started on clavamox.; 12/30: Added gabapentin; CBC; Moderate regenerative anemia; Marked leukocytosis characterized by a marked neutrophilia with bands, marked monocytosis, moderate; lymphocytosis. ; Mild thrombocytopenia; Chem; Moderate hypoglycemia; Mild azotemia; Mild hyperproteinemia; Mild hyperglobulinemia; Subjective: BARH. Eating chicken this morning. No c/s/v/d but has purulent nasal d/c on the right side.; Objective ; P = wnl ; R = eupneic ; BCS 5/9; EENT: nuclear sclerosis ou with no ocular d/c, ears clean with hair in canals AU, unilateral purulent nasal d/c on right side; Oral Exam: resistant to oral exam; PLN: No enlargements noted; H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic; ABD: Non painful, no masses palpated; U/G: MI, 2 testicles descended; MSI: Ambulatory x 4, skin free of parasites, no masses noted, thinning hair coat; CNS: mentation appropriate – no signs of neurologic abnormalities
Assessment: Geriatric; Nuclear sclerosis ou; Grade 2/4 luxating patella on the right; Thinning haircoat r/o unkempt vs endocrine vs other; Severe dental disease with nasal discharge – R/O tooth root abscesses vs other; Bruising – R/O blood/coag disorder; Regenerative anemia; Marked inflammatory leukogram consistent with degree of dental disease/oral infection; Hypoglycemia likely due to lack of nutritional intake; Mild azotemia – R/O dehydration vs renal vs other; Hyperproteinemia, hyperglobulinemia consistent with inflammation/infection/dental disease; Plan: Continue to monitor while at BACC; Rec dental with rads with placement; Continue clavamox until 1/8; Start clindamycin 7.5mg/kg PO BID until 1/8-if no response discontinue after 3 days; Continue gabapentin 10mg/kg PO SID until 1/5; Prognosis: Fair

Details on my behavior are…

Spay/Neuter status:  No
Means of surrender (length of time in previous home):  Stray
Date of assessment:  30-Dec-2017

Look:  1. Dog’s eyes are averted, ears are back, tail is down, relaxed body posture. Dog allows head to be held loosely in Assessor’s cupped hands.

Sensitivity:  1. Dog stands still and accepts the touch, eyes are averted, and tail is in neutral position with a relaxed body posture. Dog’s mouth is likely closed for at least a portion of the assessment item.

Tag:  1. Dog follows at the end of the leash, body soft.
Paw squeeze 1:  1. Dog gently pulls back his/her paw.
Paw squeeze 2:  1. Dog gently pulls back his/her paw.
Toy:  1. No interest.
Summary:  Winter came into the room calm and quiet, he was friendly and social towards the handlers.
Summary (1):

Winter was brought in as a stray so his past behavior with other dogs is unknown.
12/28: When off leash at the Care Center, Winter greets a group of small male and female dogs with a soft posture. She explores the pens, mostly keeping to herself.

Date of intake:  28-Dec-2017
Summary:  Friendly, mellow and allowed all handling.
Date of initial:  28-Dec-2017
Summary:  Very sweet and allowed handling.

ENERGY LEVEL:  Winter displays a low activity level in the care center.

BEHAVIOR DETERMINATION:  AVERAGE (suitable for an adopter with an average amount of dog experience)
Behavior Asilomar
H – Healthy

You may know me from such films as…

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