ROOTBEER – A1111216
Safe - 5-10-2017 Brooklyn
[email protected] and they will help answer any questions you may have.
ROOTBEER – A1111216
MALE, RED, COCKER SPAN MIX, 10 yrs
STRAY – EVALUATE, NO HOLD Reason STRAY
Intake condition UNSPECIFIE Intake Date 05/06/2017, From NY 11231, DueOut Date 05/09/2017,
Medical Behavior Evaluation BLUE
Medical Summary DVM Intake Exam Estimated age: 8 years Microchip noted on Intake? none History : found outside home Subjective: severely matted Observed Behavior – quiet, painful on exam of eyes and ears Objective T = P = 110 R = 30 BCS=5/9 EENT: eyes-cannot examine well, severe mattind and dry discharge around eyes. ears- swollen AU, painful nasal- no discharge Oral Exam: severe calculus buildup on premolars/molars. periodontal disease PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: tense on palpation, no masses noted U/G: intact, both testicles descended MSI: Ambulatory x 4, no masses noted, severely matted coat. swelling, alopecia and lichenification of dorsal surfaces of paws CNS: mentation appropriate – no signs of neurologic abnormalities Rectal: not indicated Assessment 1.ear ddx: yeast vs bacterial infection 2.severe matting ddx:poor care 3.alopecic,swollen paws ddx: atopy, demodex, pyoderma, self trauma Plan convenia-1.18 mls of 80 mg/kg given clip mats tomorrow clean ears tomorrow, start medicating for yeast anf bacterial infection rabies, dhpp, hw ag, implant microchip, flea/tick treatment neuter once skin clears of infection Recommend dental, potential for extractions Prognosis: Fair SURGERY: Temporary waiver due to pyoderma
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