JEZIBELLE – A1119838

JEZIBELLE – A1119838

FEMALE, TAN / WHITE, SHIH TZU MIX, 3 yrs
STRAY – EVALUATE, NO HOLD Reason STRAY
Intake condition UNSPECIFIE Intake Date 07/26/2017, From NY 11433, DueOut Date 07/29/2017,

Medical Behavior Evaluation GREEN
Medical Summary DVM Intake Exam Estimated age: 3 Microchip noted on Intake? neg History : Brought in by police Subjective: Dull/ obtunded. Sternal but able to stand. 10% dehydrated. Observed Behavior – Quiet. Easily handleable Evidence of Cruelty seen – yes, marked matts Evidence of Trauma seen – n Objective T = 101.1 P = 96 R = eup BCS= 4/9 EENT: Eyes – cloudy cornea OU, unable to see pupils, minimally visual (sees shadows), mild- mod scleral injection, corneal black pigmentation with some neovascularization. Ears dirty with hair growing but no discharge, mildly erythematous. No nasal discharge noted Oral Exam: mild tartar, minimal gingivitis. MM pk. PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Distended abd, non painful, no masses palpated. U/G: Female. Prominent nipples – no milk. Vulva small, no discharge. No spay scar seen. Normal urine during exam. MSI: Ambulatory x 4. Mild dorsal muscle wasting. Dirty haircoat. Severe matts on all four legs and around ears/ neck. Maggots seen in matt LFL and RRL. Large sore under matt LFL. Few ulcers and mild dermatitis in dorsal metatarsal area. Marked ulceration dorsal LFL from carpus down to toes. Nails – long but not impeding gait. CNS: mentation appropriate – no signs of neurologic abnormalities Rectal: Formed brwon stool, no blood, NSF. Assessment: 3 yo intact female Shih Tzu X Marked dehydration. Severe matts. Maggot infestation. Distended abd Cloudy cornea – r/o KCS vs other Plan: Shave down. Clean legs with chlorhex. Bathe once stable. Abd x-rays – stomach distende with ingesta, large amt feces in colon with some gas – r/o constipation. NO masses seen. Unable to visualize kidneys and spleen. Liver NSF. Chest: cardiac silhouette WNL, else NSF. SQF 100 cc now, repeat 100 cc post shave. Pen G 0.7cc SQ. Clavamox 1.4 cc po BID x 10 days. Keep in medical. Re-check VC tomorrow. Consider BW if status not improved. Monitor BM, eating. Prognosis: Guarded based on response to hydration. SURGERY: Temporary waiver due to dehydration.
Weight 13.2

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