DIEGO – A1102346

DIEGO – A1102346

MALE, BROWN / BLACK, CHIHUAHUA SH MIX, 10 yrs
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition EXAM REQ Intake Date 01/27/2017, From NY 10453, DueOut Date 01/30/2017,

Medical Behavior Evaluation GREEN
Medical Summary 1/27/17 Sex: Male intact Scan: Negative Estimated age: 10-12 years old Fleas: Large amount of flea dirt. S: Slightly nervous but allows all handling, nail trimming etc. O: BAR-H, BCS 6/9, MMs pink and moist EENT: Large cataracts OU. No discharge OU, AU, nose. Moderate tartar and gingivitis. PLNs: Not enlarged. H/L: NSR, NMA. Eupnic, quiet lung sounds. Abd: Semifirm, round, no pain on palpation, no masses palpated M/S/I: Moderate medial buttressing in left stifle. Severe medial buttressing in right stifle, medial patellar luxation grade 4/4 in right stifle. Severe erythema and large amount of blood crusted in fur over shoulder blades and in axillae, some excoriations and scabbing in axillae. Flea dirt. Long nails. UG: Male intact, cryptorchid (cannot palpate L testicle) Shaved and cleaned the scabbed and crusted areas – pt severely pruritic! Trimmed nails on hind feet. A: 1. Geriatric 2. Cataracts OU 3. Pruritus, erythematous skin over shoulder blades and in axillae, lots of dried blood in fur, some active excoriations – R/O fleas vs. other pruritic condition 4. Cryptorchid 5. Dental disease 6. Medial buttressing in both stifles (worse R than L), MPL right stifle Short-term prognosis: Fair P: 1. Administered pyrantel (0.35 ml PO) and Activyl (dog 4-14 lbs) during exam 2. CBC/chemistry 3. Benadryl 12.5 mg PO once today 4. Meloxicam 1.5 mg/ml LIQUID, 0.4 ml PO tonight and then 0.2 ml PO SID x4 more days 5. Pt will likely need close monitoring to be sure he is comfortable ambulating, given arthritis and cataracts 6. Consider neuter – pt is too old for neuter at ACC but this procedure is recommended for this patient because he is cryptorchid. Cryptorchid testicles are at high risk for developing cancer. 1088
Weight 6.8

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