MYA – 15250
Safe - 12-7-2017 Manhattan Rescue: Rescue Dogs Rock NYC Please honor your pledges: http://rescuedogsrocknyc.org/donate/
Hello, my name is Mya. My animal id is #15250. I am a desexed female white dog at the Manhattan Animal Care Center. The shelter thinks I am about 10 years old.
I came into the shelter as a owner surrender on 02-Dec-2017, with the surrender reason stated as animal health – other.
Mia is a geriatric girl at risk due to medical condition. She is underweight, anemic with possible underlying conditions, in addition to a severe ear infection. she should go to an average home that can manage her medical care.
My medical notes are…
Weight: 31 lbs
[DVM Intake] DVM Intake Exam Estimated age:10 Microchip noted on Intake? n History : owner surrender Subjective:emaciated w/ visible wound right shoulder Observed Behavior – painful and scared, able to examine all but ear Evidence of Cruelty seen -n Evidence of Trauma seen -n Objective T = P = 130 R = wnl BCS 3/9 EENT: Eyes clear, as overtly wnl, AD severely thickened – calcified otic canal w/ serosanguinous d/c from ear, could not examine awake, no nasal or ocular discharge noted Oral Exam: muzzled PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated, emaciated U/G: f/s MSI: Ambulatory x 4, but emaciatedskin free of parasites, right shoulder 10 x 10 cm area of an ulcerated wound, no masses noted, healthy hair coat CNS: Mentation appropriate – no signs of neurologic abnormalities Rectal: na Assessment: approx 10 yr fs mix breed hx of chronic otitis w/ serosanguinous fluid and calcification of ear canal – r/o bact vs yeast vs dietary vs surgical at this time large wound right shoulder Prognosis: wound – excellent ear – guarded to good for long term, good for short term Plan: needs sedation to clip and clean wounds and further evaluate ear going to start baytril to get into middle ear canal if otitis media as well. SURGERY: Temporary waiver due to underweight and current condition
Hx: owner surrender with severe chronic otitis and large wound on R shoulder S/O -QAR, a little shy but sweet and docile -good appetite, very pruritic-excessively scratching at ears and along wound on shoulder -mm pk, sl tacky; CRT <2 sec; mild discoloration of upper canines; mild chronic wearing on upper premolars -no nasal discharge or sneezing -AD: fleshy growth at entrance to canal; moderate to severe inflammation, lichenification with severe erythema and ulceration of canals; generalized bleeding, may be coming from irritation around growth -AS: moderate stenosis of external ear canal with inflammation, lichenification of canal; no significant erythema -large ulcerated wound/hot spot on R shoulder; suspect it is self induced secondary to scratching due to pruritus -eupnic, no murmurs/arrhythmias -soft abdomen -ambulatory x 4 with no noted lameness -BCS 4/9 A 1. Otitis externa, chronic 2. Growth AD, suspect benign but is likely a major contributing factor to chronic otitis 3. Large wound/hot spot-suspect secondary to pruritus/scratching 4. Geriatric 5. Anemia-r/o secondary to chronic otitis and wound vs other P -sedated with 0.3 ml dexdomitor/0.3 ml torb IM -flushed ear canals, applied osurnia, 1 tube AU; repeat osurnia in 7 days -clipped/cleaned large hot spot -d/c rimadyl -gave dexamethasone SP 4 mg/ml: 0.5 ml IM -continue baytril PO -gabapentin 100 mg PO BID
CBC-mild to moderate non regenerative anemia (26%) Chemistry-WNL A Anemia-r/o secondary to severe otitis and wound vs other P recommend recheck CBC in 10-14 days
S/O -QAR, docile and friendly -good appetite -mm pk, tacky; CRT <2 sec -no nasal discharge or sneezing -AD: moderate generalized blood tinged purulent weeping along pinna and external ear canal but significantly less bloody than yesterday and seems more comfortable -large hot spot over R shoulder appears to be drying out along edges but center remains actively ulcerated -overall appears much more comfortable today, no scratching or head shaking noted A 1. Chronic, severe otitis (AD>>>AS) 2. Large hot spot, suspect partially or completely self induced secondary to scratching 3. Underweight 4. Mild anemia-r/o chronic wound vs other P -tomorrow start prednisone 10 mg PO SID x 5 days, then 5 mg PO SID x 5 days, then 5 mg EOD x 5 doses -famotidine 30 mg PO SID x 5 days -consider removal of growth at ear canal AD -recommend trying apoquel long term to manage chronic otitis, consider diet trial with hypoallergenic diet
Hx: Growth at entrance to canal AD, secondary chronic otitis, secondary chronic wound on the right shoulder. Was started on Rimadyl but this was discontinued. Received Osurnia. Currently receiving Baytril, Gabapentin, prednisone, famotidine. S: Calm in kennel, allows all handling, wags tail, relaxed O: BAR, BCS 3/9, MMs pink and moist, CRT <2 sec EENT: AS NSF. AD moderate brown moist discharge. No discharge OU, nose. Mild staining on teeth, maxillary canines are pink and dull, slightly pitted. H/L: Eupnic, not ausculted today Abd: Soft, no pain on palpation, no masses palpated M/S/I: Amb x4. Large wound on right shoulder – granulation tissue visible, moderate moist discharge. Alopecic tail gland. Neuro: Alert and appropriate, no sign neurological deficiencies A: 1. Mass AD, chronic otitis and wound on shoulder – doing well on treatment 2. Discolored maxillary canines; likely devitalized 3. Anemic 4. Underweight Short-term prognosis: Good-fair P: 1. CWCT 2. Recommend bx of mass and excision if possible 1088
S/O -BAR, friendly and docile, love this girl! -good appetite, urination large amount of clear/yellow urine this morning -mm pk, moist; CRT <2 sec -no nasal discharge or sneezing -OD: mild mucoid d/c -AD: resists exam but overall inflammation along external ear canal significantly improved; moderate tan mucoid discharge present but improved; stenosis of external ear canal with pink, fleshy growth -AS: previous moderate otitis resolving -large area of moist dermatitis along R shoulder; mild pruritus but appears comfortable overall; edges of wound drying out but center is still actively ulcerated -eupnic -underweight A 1. Severe otitis AD with growth/stenosis of canal 2. Geriatric 3. Moist dermatitis 4. Underweight 5. Anemia P extend baytril x 7 days, continue other treatments
Details on my behavior are…
Behavior Condition: 2. Blue
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