SOCCER – A1111625
Safe - 5-11-2017 Brooklyn
SOCCER – A1111625
ALE, BLACK / WHITE, SHIH TZU MIX, 9 yrs
STRAY – STRAYAVAI, HOLD RELEASED Reason STRAY
Intake condition UNSPECIFIE Intake Date 05/10/2017, From NY 11233, DueOut Date 05/13/2017,
Medical Behavior Evaluation BLUE
Medical Summary Estimated age: 9 yrs. Microchip noted on Intake? Yes #101552560. Stray dog, noted to be severely matted at arrival. Dog was shaved before exam due to severity of matting. Quiet, calm, allows all handling. QARH. mm=lt pink, moist, CRT<2 s. HR=100, RR=24. BCS=5/9. ORAL: Mod. calculus, gingivitis. Missing teeth. EENT: OU-Appear dry, with debris and fur stuck to surface of cornea. Mild scleral injection, no ocular discharge. No nasal discharge. AU-Erythema, tan debris. PLN: No enlargements noted. H/L: Lungs clear, no murmurs/arrhythmias. ABD: Non painful, no masses/organomegaly palpated. U/G: Intact male, both testicles palpable. MS: Ambulatory x 4, no lameness. INTEG: Patient was shaved prior to exam so no comment can be made regarding degree of matting. Skin is dry with diffuse seborrhea. No erythema, no moisture, no open wounds. CNS: Mentation appropriate – no signs of neurologic abnormalities. A: Senior dog with likely KCS OU. Seborrheic dermatitis secondary to severe matting. Dental disease. P: Schirmer tear test OU = 0 mm/min. Flushed OU with saline solution to remove as much debris as possible. Corneas pigmented OU. Fluorescein stain OU = hazy uptake OU. Applied TAB ointment OU and Optimmune OU. Continue both eye medications BID long term. Good prognosis with appropriate management. Permanant waiver from neuter surgery due to age.
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