ECKO – A1112955
Safe - 5-27-2017 Manhattan
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ECKO – A1112955
MALE, BLACK / WHITE, SIBERIAN HUSKY MIX, 5 yrs
OWNER SUR – PRE RTO, HOLD FOR RTO Reason PET HEALTH
Intake condition EXAM REQ Intake Date 05/23/2017, From NY 10029, DueOut Date 05/25/2017,
Medical Behavior Evaluation BLUE
Medical Summary Estimated age: 4 years Microchip noted on Intake? neg, placed. Owner surrender; was originally acquired from owner’s brother; has had chronic eye issues that recently worsened in the last week; owner stated she was using visine drops but no mention of prior vet care. BAR, a little anxious but allows handling and is overall friendly; startles easily because he is blind Evidence of Cruelty seen – severe ocular disease that was left untreated BCS 4/9 EENT: OS-severe bupthalmia; cornea appears slightly dull and roughened; almost entire cornea is pigmented with significant corneal edema-able to visualize pupil slightly through dorsal aspect of cornea; superficial neovascularization OD-mod bupthalmia; hypermature cataract; focal corneal pigmentation comprising less than 25% of cornea multifocal, mild ulceration on nasal planum AS-mod crusting discharge, mild erythema/inflammation Oral Exam: mm pk, moist; CRT <2 sec; mod tartar; wearing/damage to tip of all canines PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: male intact; 2 normal descended testicles MSI: ambulatory x 4 with no obvious lameness mild diffuse muscle wasting shedding undercoat nails overgrown CNS: mentation appropriate; horizontal nystagmus OU; normal CP/reflexes x 4 Rectal: not performed Assessment 1. Bupthalmia OU-r/o glaucoma (primary vs secondary to cataracts or trauma) vs other 2. Vertical nystagmus-suspect peripheral disease due to normal proprioception 3. mild ear infection AS 4. damage to canines Plan CBC/chem Rec’d IOP to confirm/rule out glaucoma-tonopen not currently working Rec’d neuro consult to evaluate for nystagmus Rec’d bilateral enucleation Rimadyl 50 mg SID x 14 days do not want to treat mild otitis externa until further work up for nystagmus Prognosis: good with enucleation SURGERY: temp waiver due to nystagmus/ocular dz
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View all entries in: Safe Dogs 2017-05