SIMBA – A1100169

SIMBA – A1100169

MALE, BROWN / GRAY, YORKSHIRE TERR MIX, 8 yrs
OWNER SUR – EVALUATE, NO HOLD Reason MOVE2PRIVA
Intake condition EXAM REQ Intake Date 12/20/2016, From NY 10468, DueOut Date 12/20/2016,

Medical Behavior Evaluation BLUE
Medical Summary 12/20/16 Sex: Male intact Scan: Negative Estimated age: 8 years as reported by previous owner Fleas: No flea dirt. Hx: Was vaccinated at about 4:20pm, now appears to be having a vaccine reaction – vomited bile and began scratching ears obsessively. S: Nervous, allows handling, doesn’t settle. O: BAR-H, BCS 5/9, MMs pale pink and moist, CRT < 2 sec EENT: Hyperpigmentation and mild lichenification of both pinnae, mild discharge visible AU. Fresh scratches visible in front of both ears. No discharge OU, nose. Moderate 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. No skin lesions noted. UG: Male intact, testicles soft and symmetrical. A: 1. Possible vaccine reaction – if a true vaccine reaction, very mild 2. Chronic otitis externa Short-term prognosis: Good P: 1. Administering dexamethasone 2 mg SQ, diphenhydramine 50 mg/ml 0.35 ml SQ, famotidine 10 mg/ml 0.5 ml SQ 2. Monitor in Medical overnight 3. If doing well tomorrow, okay to move out of Medical 4. Pyrantel 0.7 ml PO and Activyl 1088
Weight 10.0

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