BUSTER – A1106855

BUSTER – A1106855

NEUTERED MALE, GRAY / WHITE, SHIH TZU MIX, 3 yrs
STRAY – ONHOLDHERE, HOLD FOR EVENT Reason OWNER DIED
Intake condition UNSPECIFIE Intake Date 03/22/2017, From NY 11212, DueOut Date 03/25/2017,

Medical Behavior Evaluation GREEN
Medical Summary  Was seen at ASPCA community clinic in 10/2016 and 11/2016, prescribed Benadryl, Aurocin ear cleanser, Entederm ear tx, multiple shampoos, Genteal eye drops. Novel protein food trial was recommended. Subjective Energetic, relaxed, allows all handling Objective BCS 4/9 MMs pink and moist EENT: Moderate mucoid discharge OU. Signs of chronic ear irritation – lichenification, moderate yellow aural discharge in fur in ears. No nasal discharge noted. Oral Exam: Underbite, mild tartar PLN: Prescapular and popliteal LNs are enlarged, symmetrical. Mandibular LNs are not enlarged. H/L: Grade 3/6 systolic heart murmur, PMI L base, soft on R side. NSR. CRT < 2. Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: Male neutered MSI: Ambulatory x 4, healthy stifles, no sign MPLs. Fur is thin over caudal half of dorsum – underlying skin is lichenified, thickened, hyperpigmented, dry and crusty. Severe pododermatitis – all four feet are alopecic and mildly swollen, with bright red or hyperpigmented skin. CNS: Mentation appropriate – no signs of neurologic abnormalities Assessment: 1. Underweight 2. Severe chronic dermatitis – R/O allergies to environmental triggers vs. food, vs. other 3. Heart murmur 4. Enlarged LNs – R/O chronic inflammatory response from allergies Plan: 1. Benadryl 25 mg PO BID x10 days 2. Bathe with Malaseb shampoo and clean ears every other day 3. Otibiotic AU BID x10 days 4. Recommend diet trial to identify food allergens – also strongly consider intradermal skin testing to identify environmental allergens and to develop a course of injections to ameliorate these. 5. Recommend chest rads to stage heart disease 1088
Weight 16.4

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