CHEWY – 12383

CHEWY – 12383

Location: Manhattan,  Intake Date: 11/12/17,  Intake Type: Owner Surrender

Medical Behavior: Green,  Sex: Neutered,  Age: 7 years,  Weight: 4 lbs

Vet Notes: 9:57 AM; Blood work available for review: CBC-mild neutrophilia, mild monocytosis; Chemistry-mildly elevated globulins; T4-2.0; Assessment: Mild leukocytosis-r/o secondary to hypothyroidism or skin disease; T4 WNL

Vet Notes: 9:53 AM; S/O; -BAR, energetic and friendly; allows all handling; -OD: severe periocular dermatitis with serosanguinous discharge; blepharospasm with increased epiphora; pin point area of stain uptake in lateral field; -resists oral exam, previously dx with severe dental disease; -eupnic, heart/lungs WNL; -soft abdomen; -dermatitis interdigitially on front paws, mild crusting lesions over dorsum; A; 1. Hypothyroid-appears well regulated; 2. Periocular dermatitis OD-r/o secondary to rubbing due to ulcer vs atopic dermatitis vs autoimmune vs other; 3. Corneal Ulcer OD-mild; 4. Dental disease; P; dexamethasone 4 mg/ml: 0.3 ml SQ; convenia injection: ofloxacin drops OU OD x 10 days; gabapentin 100 mg PO BID x 5 days

DVM Intake Exam; Estimated age: 7yrs (reported); Microchip noted on Intake? N; History : owner surrender d/t inability to pay for medical care; Subjective: QAR; Observed Behavior – compliant but painful- limited exam performed around mouth; Objective; T = DNP; P = WNL; R = WNL; BCS 5/9; EENT: OS- blepharospasm, mild periocular erythema, no discharge noted; OD- significant ulcerative periocular inflammation/dermatitis w/ serosanguinous discharge- rubbing/pawing, mild corneal edema visible but cannot visualize globe well d/t inflammation of periocular tissues; ears clean, no nasal or ocular discharge noted; Oral Exam: stage 4/4 dental dz, oligodontia, chatters- cannot open mouth for full oral exam d/t pain; hair and tartar caked on visible teeth; PLN: Submandibular LNs prominent; H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic; ABD: Non painful, no masses palpated; U/G: Neutered male; MSI: Ambulatory x 4, ulcerative dermatitis present ventral chin w/ scarring and scabbing, similar periocular alopecia/erythema/inflammation/ulceration OD; perianal region swollen and ulcerated similar to presentation on ventral chin and periocularly OD; grade 3/4 MPLs bilat; CNS: Mentation appropriate – no signs of neurologic abnormalities; Rectal: DNP; Assessment: 1) significant skin disease present (chin/periocular OD/perianal)- ddx pyoderma, autoimmune, parasitic, 2o to hypothyroidism, 2o to dental dz (lesions on head), other; 2) severe stage 4/4 dental dz w/ concern for weaknening of mandible (unable to open mouth d/t pain/chattering); 3) hypothyroidism- currently on 0.2mg levothyroxine PO BID (own meds); 4) Grade 3/4 MPLs bilat; 5) possible corneal ulcer OD; Prognosis: Fair; Plan: Work-up for skin lesions, work-up OD and treat eye (if necessary), rec ecollar at all times, pain meds, antibiotics; rec CBC/Chem/T4; hold off on vaccines pending work-up (in case autoimmune); SURGERY: Permanent waiver due to already neutered.

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