PHIL – A1120263

PHIL – A1120263

MALE, GRAY / WHITE, HAVANESE MIX, 8 yrs
STRAY – EVALUATE, NO HOLD Reason STRAY
Intake condition EXAM REQ Intake Date 07/29/2017, From NY 10455, DueOut Date 08/01/2017

Medical Behavior Evaluation BLUE
Medical Summary  Estimated age: 8-10 years Microchip noted on Intake? neg. Found tied up outside with no one around to claim him; noted to be vocalizing in pain when attempting to defecate. QAR,  shy but allows all handling BCS 3.5/9 EENT: OU-immature cataracts, ears clean, no nasal discharge noted Oral Exam: mm pk, tacky; CRT <2 sec; severe tartar PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: soft, nonpainful; large fluctuant swelling over R rear; fecal matter in colon palpable in swelling; suspect perianal hernia U/G:male intact, 2 scrotal testicles present MSI: ambulatory x 4 with no signs of lameness moderately matted hair coat thin BCS CNS: mentation appropriate – no signs of neurologic abnormalities Rectal: R sided perianal hernia with loop of colon Assessment perianal hernia dental disease underweight Plan gave 0.1 ml hydromorphone/0.2 ml dexdomitor IM to sedate for radiographs, shavedown and further palpation-removed 2 firm/normal fecal balls from colon; colon present in cutaneous swelling to R of rectum R lateral radiographs- large swelling along hind end with multiple bowel loops present including distal colon with fecal material; ingesta in stomach gave 200 ml SQF gave 0.4 ml cerenia SQ gave carprofen 50 mg/ml 0.2 ml SQ reversed with antisedan 0.2 ml SQ continue enulose 2 ml PO TID, can add miralax if needed gabapentin 0.8 ml PO BID until placement needs surgical correction of perianal hernia ASAP Prognosis: fair to good with surgical correction SURGERY: perm waiver due to age/perianal hernia
Weight 8.6

 

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