WINTER – 20878

WINTER – 20878

15 Years Old, Small Tan Mix, Stray 02/16/18

DVM Intake Exam; Estimated age: ~15yrs; Microchip noted on Intake? no; History : Stray – owner passed away; Subjective: BARH ; Observed Behavior – Active, difficult to restrain – very squirmy – but allows all handling; Objective ; P = WNL R = WNL BCS 5/9; EENT: immature cataracts (R>>L), 2-3 masses along left upper eyelid, ears clean, no nasal discharge noted; Oral Exam: Moderate dental tartar/gingivitis; PLN: No enlargements noted; H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic, coughing on leash; ABD: Slightly distended, resented abdominal palpation; U/G: Male; MSI: Ambulatory x 4, skin free of parasites, no masses noted, bilaterally symmetrical alopecia of entire body – healthy fur at limbs and head; ~0.5cm round cystic structure at left side of neck; CNS: mentation appropriate – no signs of neurologic abnormalities; Assessment: Geriatric,  alopecia – R/O endocrine disease (cushings vs alopecia X vs other),  cataracts; coughing – R/O collapsing trachea vs other; Plan: Scheduled CBC/Chem/T4, consider thoracic radiographs for possible collapsing trachea; Prognosis: Fair; SURGERY:  Permanent waiver due to age and skin condition

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

Basic Information:  Winter is a small brown and white mixed breed. He came to the center after his owner passed away.
Previously lived with:  1 adult

Behavior Notes:  During intake, Winter was a bit tense but allowed some handling.

My medical notes are…

Blood Work Interpretation;  Vet Notes: 1:57 PM
Hematology; Mild neutrophilia 11.68 (2.95-11.64). Rule-out inflammation, acute or chronic.  Moderate thrombocytosis 671 (148-484). Rule-out inflammation vs endocrine vs neoplasia.  Chemistry; Mild increase in BUN. Rule-out pre-renal vs renal vs extra-renal.  Mild hyperglobulinemia. Rule-out inflammation vs other.  Mild-moderate hypercholesterolemia. Rule-out postprandial vs endocrine vs other.  Endocrinology; Total T4 1 (1-4) Low Normal; Note: Dogs with clinical signs of hypothyroidism and low or low normal T4 concentrations may be evaluated; further by submission of freeT4 (fT4) and canine TSH.

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