BENJI – A1112801

BENJI – A1112801

MALE, BROWN, COCKER SPAN MIX, 9 yrs
OWNER SUR – AVAILABLE, NO HOLD Reason MOVE2PRIVA
Intake condition EXAM REQ Intake Date 05/26/2017, From NY 10457, DueOut Date 05/26/2017

Medical Behavior Evaluation BLUE
Medical Summary  Estimated age: 9yrs Microchip noted on Intake? neg.  Friendly, but doesn’t like restraint, no aggression  P = 120 R = 30 BCS 5/9 EENT: Eyes clear, severe erythema, stenosis of ear canals, mild pus present, painful, malodorous, no nasal discharge noted. Moderate matting of fur on undersides of pinna bilaterally Oral Exam: muzzle on- with tongue depressor able to see pink gums, no tartar or gingivitis seen PLN: No enlargements noted H/L: NSR, No arrythmia, but grade 2/6 systolic HM, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: MI, both testicles descended normal consistency MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat CNS: mentation appropriate – no signs of neurologic abnormalities Assessment Plan cleaned ears as best as could=p painful, sternotic ear canals. Applied 1tube of osurnia into each ear then gently massaged ear canals recheck ears in 7 days, apply second dose of osurnia (1tube per ear) at that time. requested cbc/chem/t4 (if available) in house baytril 136mg: 1T PO SID x14 days, then recheck ears long term consider cardio consult for possible ECHO to determine underlying cause of HM Prognosis: poor to fair for ears- this will be a chronic issue with flair ups, and may require c/s of the ears, possible TECA sx Surgery: Permanent waiver due to geriatric status and heart murmur
Weight 33.8

 

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