ODIN – 34736
Urgent - Manhattan
SUPER URGENT 7/17/18
ODIN – 34736
Care Center Location: Manhattan, ZIP Code From: 10002, Intake Type: Stray
Medical Behavior: -, Age: 11 years, Sex: Male
Weight: – lbs
DVM Intake Exam; Estimated age: Estimated 10-15 years based on dentition and ocular changes; Microchip noted on Intake? Scanned neg; History : Given to the police with no hx; Subjective: Alert, walks well on leash, looks relaxed when he is standing on the floor while tethered; Observed Behavior – Initially has slight tail wag, allows oral exam. Gets tense and starts growling very softly when I pick scabs off his chin. Growls, struggles and vocalizes when restrained, as for blood draw. Objective ; BAR-H, MMs pink and moist, BCS 5/9; EENT: OU lens opacity – cannot determine whether it is immature cataract or nuclear sclerosis due to corneal opacity that obscures fundic exam. OU corneal opacity and neovascularization, mild mucoid sticky discharge. Ears clean. No nasal discharge. Oral Exam: Severe tartar. Large crusty scabs overlying moist dermatitis on the ventral lips. PLN: No enlargements noted; H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic; ABD: Soft, non painful, no masses palpated, not distended; U/G: Male intact, testicles S/S; MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat; CNS: Mentation appropriate – no signs of neurologic abnormalities; Rectal: Normal externally; Assessment: 1. Mucoid ocular discharge – suspect KCS, although conjunctivitis is also a differential 2. Corneal opacity and neovascularization – R/O scarring vs. active ulceration vs. both 3. Possible nuclear sclerosis vs. cataracts 4. Severe tartar, crusty scabs on ventral lips that are likely secondary to chronic hypersalivation and moist dermatitis; Prognosis: Good with appropriate follow-up diagnostics; Plan: 1. Unable to fluorescein stain today due to behavior. Treat with TAB for 5 days, then schedule STT and fluorescein stain, and consider Optimmune (indefinitely) if KCS is confirmed 2. Recommend dental cleaning ASAP with rads and extractions as needed 3. Recommend wiping lip dermatitis daily with cleansing wipes; SURGERY: Permanent waiver due to age
Details on my behavior are…
Date of assessment: 17-Jul-2018
Look: 1. Dog’s eyes are averted, with tail wagging and ears back. Allows head to be held loosely in Assessor’s cupped hands.
Sensitivity: 1. Dog stands still and accepts the touch, eyes are averted, and tail is in neutral position with a relaxed body posture. Dog’s mouth is likely closed for at least a portion of the assessment item.
Tag: 1. Dog follows at the end of the leash, body soft.
Paw squeeze 1: 1. Dog does not respond at all for three seconds. Eyes are averted and ears are relaxed or back.
Paw squeeze 2: 1. Dog does not respond at all for three seconds. Eyes are averted and ears are relaxed or back.
Toy: 1. Minimal interest in toy, dog may smell or lick, then turns away.
Summary: Odin approached the assessor with a soft body. He was social, allowed all handling, and displayed no concerning behaviors.
Summary (1): 7/17: When introduced off leash to dogs, Odin keeps mostly to self.
ENERGY LEVEL: We have no history on Odin so we cannot be certain of his behavior in a home environment. In the care center, he displays a medium level of activity.
BEHAVIOR DETERMINATION: AVERAGE (suitable for an adopter with an average amount of dog experience)
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