BENNY – A1087912

BENNY – A1087912

MALE, BLACK / BROWN, YORKSHIRE TERR / AM PIT BULL TER, 5 yrs
STRAY – STRAY WAIT, HOLD FOR ID Reason STRAY
Intake condition EXAM REQ Intake Date 08/30/2016, From NY 10458, DueOut Date 09/02/2016,

Medical Behavior Evaluation YELLOW
Medical Summary Sex: Male intact Scan: Negative Estimated age: 2-5 years based on dentition Fleas: No flea dirt. S: Passive, crouched to table, tense body, did not move at all during exam or vaccines – appeared shut down. Police reported pt was snapping at them. O: BAR-H, BCS 6/9, MMs pink. Muzzled for exam. EENT: Superficial abrasion dorsal to OD. Periocular skin is alopecic, thickened and hyperpigmented. No discharge OU, AU, nose. Mild tartar, moderate gingivitis. PLNs: Not enlarged. H/L: NSR, NMA. Eupnic, quiet lung sounds. Abd: Tucked up, no pain on palpation, no masses palpated M/S/I: Amb x4. Smelled like anal glands were recently expressed. No skin lesions noted. UG: Male intact, testicles soft and symmetrical. A: 1. Alopecia, thickened skin and hyperpigmentation surrounding eyes – R/O allergies vs. other condition 2. Mild tartar, moderate gingivitis Short-term prognosis: Good to fair P: 1. Administered Activyl 14-22 and pyrantel 2 ml PO during exam. 2. Recommend thorough history-taking about periocular skin and possible medication (Benadryl 25 mg 2-3x daily) or diet trial (hypoallergenic diet, hydrolyzed diet, novel protein diet) to rule out environmental and food allergies. 3. Recommend dental cleaning in the next 2 months and then regularly (every few years) to maintain good oral hygiene. Dental disease can lead to tooth loss. 1088
Weight 20.0

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