COURAGE – A1118075

COURAGE – A1118075

**HOLD FOR LEGAL**

MALE, BROWN / WHITE, SHIH TZU MIX, 10 yrs
OWNER SUR – EVALUATE, HOLD FOR LEGAL Reason NEW BABY
Intake condition EXAM REQ Intake Date 07/10/2017, From NY 10468, DueOut Date 07/10/2017,

Medical Behavior Evaluation BLUE
Medical Summary DVM Intake Exam Estimated age: Reported 10 years old – exam is consistent with this Microchip noted on Intake? Scanned negative History : Chronic dermattiis, otitis and KCS. Pt was diagnosed with chicken allergy (but he is eating chicken at home) – got abx, they helped but clients didn’t follow up with specialist. Pt’s mother was euthanized for the same reason and this dog’s son at home is starting to develope an eye condition as well. Subjective: Calm, sits in one place. When called, pt wanders towards handler. Pt becomes tense and growls when eyes are touched but allows most other handling. Evidence of Cruelty seen – Severe dermatitis, severe otitis, severe KCS and sequelae of that. Objective BCS 5/9, MMs pink. QAR. EENT: Periocular swelling, exophthalmos, episcleral injection, mild-moderate mucoid discharge, corneal opacity – all OU but worse on left than right. Skin of head and muzzle is erythematous. Severe epithelial hyperplasia, some hyperpigmentation and some stenosis of the canals AU. Oral Exam: Did not perform PLN: Enlarged firm mandibular LNs, especially on the left. H/L: NSR, NMA Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: Male intact, testicles S/S MSI: Entire body has severely erythematous skin, with moist discharge, alopecia and edema along the ventrum, in the inguinal region and on the lower legs. Large fissures in skin of feet. Ambulatory x 4, no masses noted CNS: mentation appropriate – no signs of neurologic abnormalities Rectal: 1 cm long x 5 mm wide nodular firm perianal mass in the 5:00 position – possibly associated with anal gland. Did not perform digital rectal exam due to patient discomfort. Assessment: 1. Severe pyoderma – hx of chicken allergy 2. Chronic otitis externa 3. KCS 4. Perianal mass – R/O impacted anal gland vs. perianal tumor Plan: 1. Prednisone 5 mg tablets – 0.5 tablet PO BID x5 days, then SID x5 days, then EOD x5 doses 2. Benadryl 12.5 mg PO BID x10 days 3. Allergy-appropriate food 4. Optimmune OU BID for LIFE 5. Follow up with dermatology specialist Prognosis: Fair with treatment – guarded without SURGERY: Permanent waiver due to age. 1088
Weight 14.0

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