PETEY aka GRAPE – A1109481

PETEY aka GRAPE – A1109481

MALE, WHITE / BR BRINDLE, AM PIT BULL TER MIX, 5 yrs
STRAY – ONHOLDHERE, HOLD FOR ID Reason FIRE
Intake condition UNSPECIFIE Intake Date 04/20/2017, From NY 10474, DueOut Date 04/27/2017, I came in with Group/Litter #K17-094610

Medical Behavior Evaluation GREEN
Medical Summary  Estimated age: ~5 years Microchip noted on Intake? none. Brought in by police department; seized due to fire in building.BAR , sweet, gentle, easy to restrain/examine.  T = not taken P = WNL R = eupnic BCS 5/9 EENT: eyes/nose clear AU-mod erythema, mild-mod inflammation (worse AS) and cobblestone appearance to canal with tan discharge; AS sensitive on examination Oral Exam: mm pk, moist; CRT <2 sec mod tartar/staining mild wearing on upper canines some damage to incisors PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: intact male; 2 scrotal testicles present MSI: grade I LH lameness with mild thigh m atrophy; good hip extension, mild drawer in stifle and mild pain on extension mod interdigitial erythema with mild purulent discharge on front feet papular dermatitis over dorsum with chronic thickening of skin and crusting, pruritic-several raised wart like, hairless cutaneous lesions over dorsum few live fleas seen mod erythema, pustules in abdomen/inguinal area coat is diffusely dirty, smells faintly of smoke CNS: mentation appropriate – no signs of neurologic abnormalities Rectal: not performed Assessment 1. LH lameness-suspect mild CCL injury 2. dermatitis-r/o atopy vs flea allergy dermatitis vs demodex vs other 3. otitis externa 4. wart like masses on dorsum-r/o secondary to chronic inflammation vs true mass Plan flush ears/apply osurnia cephalexin x 14 days benadryl x 7 days rimadyl x 7 days rec’d flea/tick preventative monthly rec’d dental prophylaxis rec’d radiographs of L hip/stifle if lameness does not resolve with pain medications, activity restriction Prognosis: good; patient will likely always have some changes to the skin due to the apparent chronicity of the dermatitis and the fact that an underlying allergy is likely the cause; the lameness is not severe and if it is a mild CCL injury, then it should resolve with pain medications and controlled activity; if lameness does not respond to pain medications, worsens, or fails to resolve then a consult with an orthopedic surgeon should be pursued SURGERY: Temporary waiver due to dermatitis
Weight 74.6

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