CUPCAKE – 35427
Safe - 7-25-2018 Manhattan
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SAFE 07/25/18
CUPCAKE – 35427
Care Center Location: Manhattan, ZIP Code From: 10457, Intake Type: Owner surrender
Medical Behavior: -, Age: 9 years, Sex: Female
Weight: – lbs
DVM Intake Exam; Estimated age: ~5-7yrs based on PE ; Microchip noted on Intake? scanned negative by LVT. MC placed by LVT on intake. History / Subjective – Surrendered by O; O moving to new building where pets are not allowed ; Observed Behavior BAR, friendly but quiet. Allows all handling. Objective ; BCS 5/9 ; EENT: MIld mucoid discharge, OU; ears have moderate yellow exudate, AU; no nasal or ocular discharge noted; Oral Exam: dc 2/5; pd 2/5 ; PLN: No enlargements noted; H/L: NMA, CRT < 2, Lungs clear, eupnic; ABD: Non painful, no masses palpated; U/G: suspect intact female. no spay scar or tattoo seen. MSI: Ambulatory x 4, skin free of parasites, no masses noted. alopecia along the eyes, OU and all 4 paws to varying degrees. Mild crusting of the skin along the right lateral thorax. Moderate crusting and erythema of the ventral mandibule ; CNS: Mentation appropriate – no signs of neurologic abnormalities; Rectal: grossly normal. Assessment; dermatitis — r/o atopy, contact dermatitis, food allergies, FAD ; pyoderma ; dental disease ; otitis externa ; Prognosis: good ; Plan: Schirmer tear test OS: 20, OD 16 ; skin scrape: negative ; cefpodoxime 100mg tablet — 0.25 tablet PO q24h x 10 days ; ear cleaning ; gentizol 5 drops AU q12h x 5 days ; recommend dermatology consult / work-up once adopted / placed ; repeat schirmer tear test in 3 months ; SURGERY: Okay for surgery
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