SALLY – A1121155

SALLY – A1121155

**POSSIBLY BLIND**

SPAYED FEMALE, WHITE / TAN, SHIH TZU MIX, 7 yrs
STRAY – STRAY WAIT, HOLD RELEASED Reason STRAY
Intake condition EXAM REQ Intake Date 08/07/2017, From NY 10472, DueOut Date 08/10/2017,

Medical Behavior Evaluation GREEN
Medical Summary DVM Intake Exam Estimated age: 4-8 years based on dentition and overall appearance Microchip noted on Intake? Scanned positive History : Stray, found outside Subjective: Calm, allows all handling Evidence of Cruelty seen – neglect – fur matted completely over eyes, pt cannot see. Pt is underweight. Objective BAR, estimated 5% dehydrated based on decreased skin turgor, BCS 3/9, MMs pink and slightly tacky. EENT: Fur matted completely over eyes, pt cannot see. After shaving – periorbital tissue is edematous, and the corneas are opaque with scar tissue. The right cornea appears small and irregular (possibly cone-shaped) in shape. Waxy discharge and matted debris in ears AU. After shaving – canals are erythematous and there are small superficial ulcerations on the pinnae. Tattoo on AS medial pinna, also epithelial hyperplasia and erythema AS. No nasal discharge noted. Oral Exam: Moderate tartar PLN: Mildly enlarged mandibular LNs H/L: NSR, NMA, Lungs clear, eupnic ABD: Tucked up, non painful, no masses palpated U/G: Female, small nipples and vulva. MSI: Nails slightly long. Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat other than on face. CNS: mentation appropriate – no signs of neurologic abnormalities Rectal: Normal externally. Clipped fur around eyes and ears following exam. Assessment 1. Likely bind 2. Matted fur entirely covering eyes, corneal scarring and irregular corneal shape OD – R/O KCS vs. microphthalmia vs. other ocular condition causing severe amount of discharge 3. Matted fur in ears and evidence of otitis externa 4. Underweight, mild dehydration 5. Dental disease Plan 1. Instilled Osurnia AU today, repeat in 7 days 2. Place third feeding sign 3. Perform Schirmer tear test when eyes have not just been cleaned and flushed with eye wash 4. Okay for spay 5. Rimadyl 12.5 mg PO SID x5 days Prognosis: Good SURGERY: Okay for surgery 1088
Weight 8.2

Profile:

08/07/17 13:05

Basic Information:

Sally is roughly about 8 years old and she’s a white and tan small breed pup. She was found outside of finder’s home with no collar or leash on. The finder couldn’t keep her though because his landlord doesn’t allow pets in his apartment.

Behavior during Intake:

Sally wasn’t very responsive when I approached, I approached by whistling and I didn’t get a reaction so I clapped a few twice then everything at once and thought she may have no hearing. I crouched down to pet her and she didn’t know I was there and bumped into my legs, when I pet her she flinched. I then raised her hair above her eyes and noticed they were matted shut so she has no sight either. She allowed all handing including collar and getting her picture taken.

 

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