BOBBY – A1108333

BOBBY – A1108333
NEUTERED MALE, CREAM / WHITE, SHIH TZU MIX, 11 yrs
OWNER SUR – EVALUATE, HOLD RELEASED Reason MOVE2PRIVA
Intake condition EXAM REQ Intake Date 04/09/2017, From NY 11216, DueOut Date 04/12/2017,

Medical Behavior Evaluation GREEN
Medical Summary DVM Intake Exam Estimated age: Reported to be 11 years old – dentition and overall appearance are consistent with this Microchip noted on Intake? Negative History : Surrendered, no hx given Subjective: Calm, allows all handling Objective BCS 5-6/9, MMs pink and moist EENT: Thick mucoid ocular discharge OU – pigment keratitis. Moderate yellow discharge AU with some epithelial hyperplasia. No nasal discharge noted Oral Exam: Moderate tartar, gingivitis, gingival recession PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: Male neutered MSI: Ambulatory x 4, good stifles, no MPLs. Skin free of parasites, no masses noted, healthy hair coat, well-groomed. Slightly long nails. CNS: Mentation appropriate – no signs of neurologic abnormalities Rectal: Not performed Schirmer tear test – ZERO mm tear production in 60 seconds OU Assessment 1. Geriatric 2. Dental disease 3. KCS 4. Otitis externa Plan: 1. Start Optimmune BID and continue it **for life** 2. Clean ears today, Instill Osurnia 1 tube AU today, repeat in 7 days 3. Recommend dental cleaning, some extractions may be needed Prognosis: Fair 1088
Weight 14.0

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