GYPSY – A1112081
Safe - 5-17-2017 Manhattan
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SAFE 05/17/17
GYPSY – A1112081
SPAYED FEMALE, WHITE / GRAY, SHIH TZU MIX, 12 yrs
OWNER SUR – ONHOLDAVAI, HOLD RELEASED Reason PET HEALTH
Intake condition EXAM REQ Intake Date 05/15/2017, From NY 10461, DueOut Date 05/15/2017,
Medical Behavior Evaluation GREEN
Medical Summary DVM Intake Exam Estimated age:Reported 12 years – exam is consistent with this Microchip noted on Intake? Scan positive History : “She has suffered from chronic ear infections ever since she was a puppy. She has also developed a skin irritation for the past 5 years and over the past three months it has worsened. The family has taken her to the vet for ear infections and they have treated with medications but they haven’t been very consistent with it. They have also noticed that Gypsy has allergy flare ups when she eats Beneful.” Subjective: Calm, likes affection, leans into head scratches, allows all handling Objective BCS 6/9, MMs pink and moist EENT: AU moderate yellow moist discharge, erythema. Eyes clear, no nasal discharge noted Oral Exam: Moderate tartar H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: Female, reported spayed, small nipples MSI: Skin on legs and ventrum is thickened and very edematous, erythematous, thin fur coat, patches of hyperpigmentation. Dermatitis is especially severe in axilla, inguinal region, ventral neck and caudal legs. Ambulatory x 4, skin free of parasites, no masses noted. CNS: mentation appropriate – no signs of neurologic abnormalities Assessment: Otitis and severe generalized dermatitis. Based on history (not seasonal, and flare-ups noticed when pt eats Beneful food), this is most likely due to severe food allergies. Plan 1. Benadryl 25 mg PO BID x14 days (or longer) 2. Simplicef 50 mg PO SID x14 days (or longer) 3. Malaseb bathing twice weekly 4. Feed hydrolyzed diet or limited ingredient diet ONLY 5. Rimadyl 25 mg PO SID x7 days 6. Clean ears every 3 days and apply Otibiotic AU BID x10 days Prognosis: Fair. Will likely need strict diet to get the dermatitis and otitis under control 1088
Weight 14.0
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View all entries in: Safe Dogs 2017-05