PRINCESS – A1099022
RTO SAFE 12/08/16
PRINCESS – A1099022
FEMALE, WHITE, SHIH TZU MIX, 3 yrs
OWNER SUR – EVALUATE, NO HOLD Reason LLORDPRIVA
Intake condition EXAM REQ Intake Date 12/07/2016, From NY 10458, DueOut Date 12/10/2016, I came in with Group/Litter #K16-083735.
Medical Behavior Evaluation BLUE
Medical Summary 12/7/16 Sex: Female Scan: Negative Estimated age: 4 years as reported by previous owner Fleas: No flea dirt. Hx: No history given, but previous owner was given the dog about 4 months ago. While in cage prior to exam, pt finished two full bowls of water. She was offered food twice, and both times she jumped on it and ate the full bowl very quickly. S: Calm, allows most handling. Does not like close exam of eyes or face – in response to this, pt opens jaws very wide and very slowly turns her face as if she is going to bite, but she doesn’t close her jaws all the way. O: BAR-H, BCS 1/9, MMs pink and moist EENT: Mild conjunctival erythema, moderate green mucoid discharge OU that is matted into fur around the eyes. No discharge AU, nose. Mild tartar and gingivitis. PLNs: Not enlarged. H/L: NSR, NMA. Eupnic, quiet lung sounds. Abd: Soft, no pain on palpation, no masses palpated M/S/I: Amb x4. Long nails. No skin lesions noted. UG: Female A: 1. Severely emaciated!! Polyphagic and polydipsic – R/O endocrine disease such as diabetes vs. hyperthyroidism vs. EPI vs. other metabolic disorder. (Starvation is less likely due to pt having lived with another dog in the same house who is well-appearing.) 2. Mucoid ocular discharge – R/O viral or bacterial conjunctivitis vs. contact irritation from fur in eyes vs. other 3. Mild dental disease Short-term prognosis: Fair Current surgery status: Temporary waiver for severe emaciation. P: 1. Administered 0.4 ml pyrantel PO and Activyl for dogs 4-14 lbs during exam 2. Trimmed crusty fur around eyes (pt would not allow trimming of all fur covering the eyes) and cleaned eyes with eye wash, applied erythromycin ointment OU 3. Start TAB OU BID x10 days 4. CBC/chemistry (and UA if possible) to evaluate metabolic state 1088
CAME IN WITH: SHIVER – A1099021 (NOT AN URGENT DOG)
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