LUCKY – A0987703
Safe - 12-24-2016 Manhattan Rescue: RTO Please honor your pledges:
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RTO SAFE 12/24/16
LUCKY – A0987703
NEUTERED MALE, BLACK / WHITE, LHASA APSO, 7 yrs
OWNER SUR – ONHOLDHERE, HOLD FOR ID Reason PET HEALTH
Intake condition EXAM REQ Intake Date 12/20/2016, From NY 10461, DueOut Date 12/20/2016,
Medical Behavior Evaluation BLUE
Medical Summary 12/20/16 Sex: Neutered Scan: Positive! Estimated age: 7 years as per our previous records (was here in 2013) Fleas: No flea dirt. Hx: “Owner stated his pet is bleeding form the anus and has difficulty pooping. This pet came in with medication “metronidazole”. In kennel bag.” Rx is metronidazole 50 mg tabs, 1 tab PO SID x7 days. S: Nervous, quiet, allows all handling including rectal exam and ear cleaning O: BAR-H, BCS 4.5/9, MMs pink and moist, CRT <2 sec EENT: Moderate waxy yellow discharge AU, fur in ear canals. No discharge OU, nose. Severe tartar and gingivitis. PLNs: Not enlarged. H/L: NSR, NMA. Eupnic, quiet lung sounds. Abd: Soft, no pain on palpation, no masses palpated M/S/I: Amb x4. No skin lesions noted. Fur around anus is stained, possibly from diarrhea or blood. UG: Male neutered Rectal exam: Anus is erythematous and slightly protruding. Small anal glands, no palpable thickening of rectal walls, no prostatic enlargement. A: 1. Reported difficulty pooping and bleeding from anus – possibly straining (tenesmus) and hematochezia, secondary to gastritis or other GI disease, vs. abdominal mass causing physical obstruction. 2. Severe dental disease Short-term prognosis: Good to fair depending on nature of GI problem P: 1. Continue metronidazole, monitor for diarrhea or tenesmus. Consider abd rads if not resolving. 2. Cleaned ears during exam 3. Recommend dental cleaning 1088
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