SOCCER – A1111625

SOCCER – A1111625

ALE, BLACK / WHITE, SHIH TZU MIX, 9 yrs
STRAY – STRAYAVAI, HOLD RELEASED Reason STRAY
Intake condition UNSPECIFIE Intake Date 05/10/2017, From NY 11233, DueOut Date 05/13/2017,

Medical Behavior Evaluation BLUE
Medical Summary  Estimated age: 9 yrs. Microchip noted on Intake? Yes #101552560. Stray dog, noted to be severely matted at arrival. Dog was shaved before exam due to severity of matting.  Quiet, calm, allows all handling.  QARH. mm=lt pink, moist, CRT<2 s. HR=100, RR=24. BCS=5/9. ORAL: Mod. calculus, gingivitis. Missing teeth. EENT: OU-Appear dry, with debris and fur stuck to surface of cornea. Mild scleral injection, no ocular discharge. No nasal discharge. AU-Erythema, tan debris. PLN: No enlargements noted. H/L: Lungs clear, no murmurs/arrhythmias. ABD: Non painful, no masses/organomegaly palpated. U/G: Intact male, both testicles palpable. MS: Ambulatory x 4, no lameness. INTEG: Patient was shaved prior to exam so no comment can be made regarding degree of matting. Skin is dry with diffuse seborrhea. No erythema, no moisture, no open wounds. CNS: Mentation appropriate – no signs of neurologic abnormalities. A: Senior dog with likely KCS OU. Seborrheic dermatitis secondary to severe matting. Dental disease. P: Schirmer tear test OU = 0 mm/min. Flushed OU with saline solution to remove as much debris as possible. Corneas pigmented OU. Fluorescein stain OU = hazy uptake OU. Applied TAB ointment OU and Optimmune OU. Continue both eye medications BID long term. Good prognosis with appropriate management. Permanant waiver from neuter surgery due to age.
Weight 13.8

 

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