LUCKY – 21595
Safe - 3-2-2018 Manhattan
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SAFE 03/02/18
LUCKY – 21595
Care Center Location: Manhattan, ZIP Code From: 10456, Intake Type: Owner surrender
Medical Behavior: Blue, Age: 8 years, Sex: Neutered Male, Weight: 37 lbs
DVM Intake Exam; Estimated age: 8yo; Microchip noted on Intake? yes; History : O surrender. Family cannot devote the time to care for p. They said he smells and scratches alot. Subjective: BAR. A bit nervous and skiddish, muzzled just in case. Well behaved during PE and med handling. Observed Behavior -Objective T =; P = wnl; R = eup; BCS 6/9; EENT: Eyes clear, ears clean, no nasal or ocular discharge noted; Oral Exam: muzzled. Clean incisors and canines. PLN: No enlargements noted; H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic; ABD: Non painful, no masses palpated; U/G: MN; MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat. Alopecia, irritated, and erythematous skin on ventral neck, both cranial elbows, inguinal area, and medial thighs. CNS: Mentation appropriate – no signs of neurologic abnormalities; Rectal: normal externally; Assessment : Dermatitis; Superficial pyoderma; Allergies — r/o food vs atopy vs contact vs ectoparasites; Prognosis: good; Plan: Start cephalexin 500mg PO BID x 28 days; Start diphenhydramine 50mg PO BID x 7 days; Medicated bath; Recommend allergy testing/derm consult post placement/adoption, or trying novel protein/limited ingredient diet; SURGERY: neutered
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