MAX – A1112883

MAX – A1112883

** HOLD FOR DOH-V **

NEUTERED MALE, TRICOLOR, ROTTWEILER MIX, 6 yrs
OWNER SUR – ONHOLDHERE, HOLD FOR DOH-V Reason NEW BABY
Intake condition INJ MINOR Intake Date 05/22/2017, From NY 11373, DueOut Date 06/01/2017,

Medical Behavior Evaluation ORANGE
Medical Summary DVM Intake Exam Estimated age: 6y Microchip noted on Intake? (not performed during DVM exam) History : owner surrender/bite wound victim Subjective: BARH, limited PE due to fearful/questionable behav Observed Behavior – fearful, questionable, may bite Evidence of Trauma seen – yes, bite wounds Objective BCS 8/9 EENT: Eyes clear, ears clean, no nasal discharge noted Oral Exam: not performed due to behav PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: soft, non-painful, no masses palpated; allowed limited palp. U/G: neutered male MSI: ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat except for open wounds at right shoulder region with moderated soft tissue swelling and other small surrounding abrasions; on wound was ciruclar and more medially measuring ~2 cm in diameter and another was slightly caudal down the shoulder measuring about 1 cm in diameter CNS: mentation appropriate – no signs of neurologic abnormalities Rectal: not performed Assessment – fearful/questionable behavior – obese/overweight – two open bite wounds at right shoulder region with mod. amount of surrounding soft tissue swelling/trauma Plan – clean and close wounds + pain meds + antibiotics – monitor incision and drain — remove when appropriate Sx: – premed 1.5 ml Hydro IM, induction with 0.50 ml Telazol IV, maint. on iso; 1.5 ml Rimadyl SQ – clipped hair surrounding the wounds, cleaned and prepped for surgery; cleaned, flushed and debrided wounds; undermined skin tissue connecting two wounds and to place drain — placed drain and closed small wound intradermally and closed the larger wound with internal and external skin sutures (4 external) Rx: Clavamox 375 mg PO BID x 14 days Rimadyl 50 mg PO BID x 5 days Prognosis: good
Weight 66.0

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