MONSTER – 12365
Safe - 11-16-2017 Manhattan
MONSTER – 12365
Location: Manhattan, Intake Date: 11/12/17, Intake Type: Owner Surrender
Medical Behavior: Green, Sex: Neutered, Age: 7 years, Weight: 4 lbs
DVM Intake Exam; Estimated age:reported to be 7 but appears older, 10-12 years; Microchip noted on Intake? neg; History:owner surrender with chronic history of sneezing, nasal discharge; owner has reportedly tried many things over the last several years and recently took him to the ASPCA for a dental procedure in hopes that it would help his symptoms but it did not and more recently, his nasal discharge has been bloody; appears to be only the right side ; Subjective:BAR; Observed Behavior -interactive and friendly; allows all handling; Objective ; BCS 5/9; EENT: Eyes clear; AU-mild hyperpigmentation and lichenification along pinna but canals clear; mild serosanguinous right sided nasal discharge, persistent soft sneezing and lip licking; Oral Exam:mm lgt pk, moist; many teeth previously extracted, especially along upper left quandrant; remaining teeth appear clean; no gingival concerns or obvious fistulas ; PLN: No enlargements noted; H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic; ABD: Non painful, no masses palpated; U/G: neutered; MSI: Ambulatory x 4 with chronic thickening of stifles and grade II patellar luxations, skin free of parasites, no masses noted, healthy hair coat; CNS: Mentation appropriate – no signs of neurologic abnormalities; Rectal:grossly normal ; Assessment; Chronic right sided nasal discharge, now bloody-r/o chronic inflammation vs nasal polyp vs nasal neoplasia vs chronic infection vs other; Stifle arthritis; Prognosis:open, concern for possible underlying nasal tumor but with history of chronic signs, it may just be due to uncontrolled infection/inflammation; Plan: dexamethasone SP 4 mg/ml: give 0.3 ml IM; cerenia 4 mg PO SID x 4 days; monitor reponse to dexamethasone, if signs improving, then can continue steroid therapy orally until placement; recommend CT and rhinoscopy after placement to determine underlying cause of nasal discharge/hemorrhage; SURGERY:neutered
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