NALA – 22422
Safe - 3-15-2018 Manhattan
NALA – 22422
Location: Manhattan; Intake Date: 3/9/18; Intake Type: Owner Surrender
Medical Behavior: Blue; Sex: Spayed; Age: 10 years; Weight: 37.5 lbs
Original Location: 10465
DVM Intake Exam: Estimated age: 10yo. Microchip noted on Intake? yes Microchip Number (If Applicable):985121004955131 History : O/S. O says they work too much and doesn’t have the time to care for. O says p also has ear issues. Subjective: BAR. Nervous and shaking, muzzled just in case, but was well behaved during PE and med handling, no signs of aggression, just scared. Observed Behavior – Objective: T = P = wnl R = wnl BCS 4/9. EENT: OU periocular alopecia and erythema. AS aural hematoma. AD signs of possible previous aural hematoma, pinna is thickened and irregular. AU canals appear clean. No. nasal or ocular discharge noted Oral Exam: muzzled. PLN: No enlargements noted. H/L: Grade III/VI left systolic HM, NSR. Lungs clear, eupnic. ABD: Non painful, no masses \ palpated. U/G: FS. MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat. CNS: Mentation appropriate – no signs of neurologic abnormalities. Rectal: NE Assessment: HM AS aural hematoma. AD previous aural hematoma. history of otitis external. periocular alopecia/erythema — r/o related to otitis and allergies Prognosis: good Plan: Treatment in Medical for aural hematoma repair. Osurnia 1mL AU. Repeat in 1 week. ctm at MACC until transfer/adoption. Recommend cardio consult and echo post. placement/adoption. SURGERY: spayed. Sedated with 0.5 cc dexdomitor and 0.5 cc butorphanol IM . AS drained with 18 GA needle and flushed with Saline with 60 cc syringe. 4 mg Dexamethasone placed intralesionally and bandage placed. Otoscopic exam. performed, no obvious evidence of infection. 1 ml Osurnia given AS A: AS aural hematoma. r/o infectious versus inflammatory cause. P: remove bandage in 3 days. May require repeat treatment, (triamcinolone more effective), consider Sx approach if recurrent.
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