POLO aka RAZOUL – A1080180

POLO aka RAZOUL – A1080180

NEUTERED MALE, WHITE / BLACK, AM PIT BULL TER MIX, 2 yrs
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition EXAM REQ Intake Date 07/06/2016, From NY 10458, DueOut Date 07/09/2016,

Medical Behavior Evaluation BLUE
Medical Summary Sex: Male intact Scan: Negative Estimated age: 2-3 years based on attitude and dental tartar Fleas: No flea dirt. S: Very friendly, wags tail energetically when approached, gently puts front paws up on examiner’s waist. Growls and resists when scrotum is examined. Ducks away from touch coming from directly over pt’s head (and touch to wounds on head), but no sign of aggression. O: BAR-H, BCS 4.5/9, MMs pink and moist, CRT <2 sec EENT: Erythematous skin on muzzle, nose and surrounding eyes. Small superficial lacerations to face and base of ears – one laceration at the base of AD (1 cm dia), one ventral to base of AD (0.5 cm dia) and a few small lacerations on pt’s face and muzzle. No swelling or discharge from any laceration. No discharge OU, AU, nose. Mild 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. 2 cm dia scabbed wound on center of left flank. No pain on palpation, no swelling. Amb x4. UG: Male intact, testicles soft and symmetrical. A: 1. Lacerations to face and flank – R/O trauma from humans vs. other animals. If other animals: no sign of bite wounds – all lacerations are superficial and not swollen, suggesting that they are more likely to be scratches. 2. Erythema on face – R/O environmental vs. food allergies 3. Mild dental disease Short-term prognosis: Good P: 1. Clean wound on left lateral flank with chlorhex SID x5 days. Other wounds do not need treatment, just monitoring to ensure healing occurs. 2. Benadryl trial – 50 mg PO BID x7 days, monitor facial erythema for response 3. Administered Activyl 44-88 lb and pyrantel 5 ml PO during exam 1088
Weight 50.0

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