BABKA – A1101324

BABKA – A1101324

MALE, BROWN / WHITE, PEKINGESE MIX, 12 yrs
OWNER SUR – EVALUATE, NO HOLD Reason NO TIME
Intake condition GERIATRIC Intake Date 01/10/2017, From NY 10011, DueOut Date 01/13/2017,

Medical Behavior Evaluation GREEN
Medical Summary 1/10/17 Sex: Male intact Scan: Negative Estimated age: Reported to be 12 years old; medical condition is consistent with this Fleas: No flea dirt. S: Calm, slightly nervous, sits and allows all handling O: BAR-H, BCS 6/9, MMs pink EENT: Immature cataracts OU. Mild conjunctival erythema and epiphora OU. Small flat white oval deposit on cornea OS – no fluorescein stain uptake OU. Mild serous nasal discharge. Moderate waxy discharge AU. Extremely severe dental disease – large amount of calculus buildup that fully obscures the teeth, canines are mobile. H/L: Soft grade 1/6 systolic murmur PMI left base. Resp sinus arrhythmia. Slightly sniffly, quiet lung sounds. Abd: Soft, no pain on palpation, no masses palpated M/S/I: Decreased weight bearing on hind legs. Grade 3/4 medial patellar luxation on left, grade 4/4 MPL on right. Severe medial buttressing bilaterally. Significantly decreased hip extension bilaterally. Pt falls to the side when hind legs are palpated and then replaced on the ground. Mild seborrhea sicca. UG: Male intact, testicles soft and symmetrical. A: 1. Severe dental disease 2. Mild heart murmur – likely early mitral valve disease 3. Severe bilateral medial patellar luxation 4. Hip dysplasia 5. Otitis externa 6. Cataracts OU 7. White flat deposit on cornea OS – R/O lipid or calcium deposit 8. Nasal discharge – R/O secondary to tooth root abscess Short-term prognosis: Fair to poor. This pet’s only life-limiting condition is heart disease. The orthopedic disease will make mobility difficult but with a dedicated owner, this can be managed. Everything else is treatable. P: 1. Otibiotic AU BID x10 days 2. Clean ears q3 days (cleaned today) 3. CBC/chemistry tonight 4. Recommend chest rads and possibly ultrasound to better assess heart disease, followed by dental cleaning with extractions as soon as possible 5. Buprenorphine 0.3 mg/ml 0.2 ml SQ BID, consider switching to Rimadyl after CBC/chemistry 6. Consider medical vs. surgical management of MPLs 1088
Weight 6.8

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