STONE – 16845

STONE – 16845

12 yr. male white, OS:

DVM Intake Exam; Estimated age: Approx. 12 yrs per previous owner; Microchip noted on Intake? yes – 4878276B7F; History . Per previous owner, patient has a “hole” in the side of his face and the owner has sought treatment previously and cannot afford to continue further treatments. Also per owner, patient has been losing weight. Subjective: QAR on presentation, patient allowed all handling with no objection. Large, moist, and malodorous clump of fur lays over his left eye, partially occluding it. ; Observed Behavior – Calm temperment, did not object to handling. Objective ; BCS: 3-4/9; EENT: Nuclear sclerosis OU, ears clean, Large clump of fur overlying OS. Fur is malodorous and mixed with black debris. There is moderate to severe periocular erythema OS with a moist undercoat. Smaller clump of fur lies ventral to the right eye. ; Oral Exam: Severe periodontal disease; PLN: No enlargements noted; H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic; ABD: Non painful, no masses palpated; U/G: MI, testicles palpate S+S; MSI: Ambulatory x 4, skin free of parasites, no masses noted, matted hair coat diffusely; CNS: Mentation appropriate – no signs of neurologic abnormalities; Rectal: no abnormalities, soft but formed stool. ; Assessment Geriatric MI Maltese mix with:; 1. Severe periodontal disease; 2. Moist periocular dermatitis OS; 3. Matted coat; Prognosis: Good with treatment; Plan:; Suspect that patient may have had a previous draining tract secondary to a tooth root abscess that was only treated with antibiotics but likely won’t fully resolve without dental care. Recommend placement with dental cleaning + extractions and antibiotics.  Grooming is also necessary to avoid further dermatitis.  1. Start Clindamycin -15 mg/kg PO BID x 14 days. ; 2. Start Gabapentin – 5 mg/kg PO BID x 7 days and re-assess; 3. Monitor appetite and offer variety of food. If patient starts to eat, consider adding Rimadyl. If patient continues to be anorexic, consider adding mirtazapine. ; SURGERY:  Permanent waiver due to age

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