ERNIE – A1123690

ERNIE – A1123690

MALE, TAN / WHITE, SHIH TZU MIX, 9 yrs
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition GERIATRIC Intake Date 08/29/2017, From NY 10458, DueOut Date 09/01/2017

Medical Behavior Evaluation GREEN
Medical Summary  Estimated age: 8-10 years Microchip noted on Intake? History : found in park Subjective: QAR Observed Behavior – docile, allows all handling  BCS 6/9 EENT: OU-immature cataracts, mild mucoid discharge, increased epiphora; OS-corneal pigmentation ventrally AD-severe odorous mucoid discharge, severe stenosis/hyperplasia of external canal with small polyps AS-severe stenosis/hyperplasia of external canal; mild mucoid discharge Oral Exam: mm pk, sl tacky; CRT <2 sec; moderate to severe tartar, moderate staining PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: male intact, 2 scrotal testicles MSI: ambulatory x 4 with no noted lameness; mildly decreased weight bearing on RH, mild chronic thickening of stifle on LH CNS: mentation appropriate – no signs of neurologic abnormalities Rectal: not performed Assessment Otitis externa-severe Dental disease Immature cataracts Corneal pigmentation OS Geriatric Plan TAB ointment OU BID x 7 days convenia inj 1 ml SQ flush ears, otibiotic AU BID x 14 days rec’d STT CBC/chem rec’d dental cleaning after placement Prognosis: good; chronic otitis is likely exacerbated by small growths and hyperplasia of external ear canal SURGERY: permanent waiver due to age
Weight 21.0

 

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