LAYLA – A1113021

LAYLA – A1113021

FEMALE, CHOCOLATE / WHITE, PEKINGESE MIX, 10 yrs
OWNER SUR – EVALUATE, NO HOLD Reason NO TIME
Intake condition EXAM REQ Intake Date 05/26/2017, From NY 11379, DueOut Date 05/26/2017,

Medical Behavior Evaluation GREEN
Medical Summary Estimated age: Microchip noted on Intake? no. O surrender, reported to have h/o seizures, none in past three months, reported to have skin allergies  allows all handling, a little nervous during exam, resents close handling  squirming during exam, unable to get RR and HR BCS 5/9 EENT: Eyes clear, upper right lid approx 2mm pink mass contacting cornea, conus OU, ears clean, no nasal discharge noted, moist nose present, stenotic nares Oral Exam: pink gums PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic, referred upper airway sounds, difficult to ascult cardiac sounds ABD: Non painful, no masses palpated U/G: FI, no palpable MGTs, no palpable or visible spay scar or tattoo MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat except for area approx 10cm of patchy alopecia on L dorsolumbar area and smaller area on R dorsolumbar area with some areas of regrowth- skin beneath NSF. Attempted to assess ROM in HLs- p stiff and nervous, cannot manipulate limbs CNS: mentation appropriate – no signs of neurologic abnormalities Assessment brachycephalic syndrome OU conus- lagophthalmos OD upper lid mass: r/o benign vs. malignant FI skin alopecia: r/o previously shaved, scratching, other- Wood’s lamp negative- no active lesions reported to have h/o seizures by prev o and to have skin allergies by prev o Plan ok for spay Will monitor patchy alopecia for regrowth- at this time skin beneath apperas NSF eyelid mass: can pursue wedge resection and send for histopathology. Consider eye lubricants, as may have lagophthalmos and could lead to corneal scarring long term monitor for seizures- if seizures present at least 1x/month, consider anti seizure meds vs. full workup with neurologist, may include MRI and CSF tap. If any signs of allergies- rec either derm consultation with skin testing (food trial, intradermal testing) or symptomatic tx (treat itching with antihistamines, steroids, other, try hypoallergenic/limited ingredient diets such as Natural Balance, omega fatty acids, soothing skin baths. If any difficulty breathing associated with brachycephalic syndrome, may consider brachycephalic sx to correct- rec board certified surgeon Prognosis: fair to good SURGERY: Okay for surgery
Weight 12.2

 

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