SAFE – 04/06/15 JACKSON – A1032246 – BROOKLYN, NY

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SAFE – 04/06/15

Brooklyn Center

JACKSON –  A1032246

***NEEDS FOLLOW-UP VET CARE – POSSIBLE NEUROLOGICAL ISSUES***
MALE, BROWN, YORKSHIRE TERR MIX, 10 yrs
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition EXAM REQ Intake Date 04/05/2015, From NY 11434, DueOut Date04/08/2015,

Medical Behavior Evaluation BLUE
Medical Summary scan negative Male, ~ 9 years requires gentle restraint for exam slight bilateral nuclear sclerosis severe dental disease & gingivitis nasal discharge: clear, advised Dr. 1044 NOSF Heartworm negative applied activyl flea prevention
Weight 5.4

S/O: BAR, FRIENDLY, ALLOWED HANDLING W/O SIGNS OF AGRESSION, SHAKING/FEARFUL, EENM: MM PINK AND MOIST, CRT 2 SEC, MODERATE GINGIVITIS AND CALCULI, MOSTLY ALL INCISORS LOISE, NO ORAL MASSES/ULCERATIONS, SMALL HEALING WOUND WITH SCAB AND BLOOD VISIBLE (W/IN PAST 24 HRS) OS MEDIAL CANTHUS.  MILD OCULAR CLOUDING/CATARACT, CV: NO MURMURS OR ARRHYTHMIAS, LUNGS: CLEAR, ABD: TENSE, COULD NOT PROPERLY PALPATE, MS/INTEG: AMB X 4, BCS 4/9., LIMPING RHL, NO DRAWER OR MEDIAL LUXATION PALPABLE, CP DELAYED HL, HYPERMETRIC FL, WALKS SIDEWAYS. ROUND LIGAMENT WNL, SPINAL PALPATION ELICITED NO PAIN, WNL, NO FRACTURES, NO HEAD TILT/NYSTAGMUS, MENACE AND PLR (CONS AND DIRECT) POSITIVE, AU WNL, NO HERNIAS PALPABLE., DORSUM AREA ERYTHEMATOUS WITH MULTIPLE SMALL SUPERFICIAL SCRATCHES, NS: APPROPRIATE, PLN: NSF, GU: INTACT MALE, BOTH TESTES PALPATE WNL

A:

LIMPING RHL

CP DELAYED HL, HYPERMETRIC FL, WALKS SIDEWAYS.

DORSUM AREA ERYTHEMATOUS WITH MULTIPLE SMALL SUPERFICIAL SCRATCHES

MODERATE GINGIVITIS AND CALCULI, MOSTLY ALL INCISORS LOISE, NO ORAL MASSES/ULCERATIONS, SMALL HEALING WOUND WITH SCAB AND BLOOD VISIBLE (W/IN PAST 24 HRS) OS MEDIAL CANTHUS.

DDX:

NEURO: MOST LIKELY CENTRAL LESION, COULD BE MULTIPLE (TRAUMA/HBC, INFECTIOUS, INFLAMMATORY, NEOPLASTAIC VS OTHER)

P:

PUT IN MEDICAL FOR MONITORING

NO TREATMENT AT THIS TIME, COULD BE OLD LESION/NEURO

SEEK PLACEMENT/NEW HOPE

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