WILBUR – A1100939

WILBUR – A1100939

MALE, TAN / BR BRINDLE, SHIH TZU, 5 yrs
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition INJ SEVERE Intake Date 01/03/2017, From NY 10475, DueOut Date 01/06/2017,

Medical Behavior Evaluation GREEN
Medical Summary 1/3/17 Sex: Male intact Scan: Negative Estimated age: 8 years based on dentition Hx: Reportedly found 2 days ago S: Nervous, allows all handling O: BAR-H, BCS 6/9, MMs pink and moist EENT: OD: Severe corneal opacity, possibly corneal ulceration and neovascularization. OS: Small corneal defect at center of cornea with surounding edema and neovascularization. No discharge AU, nose. Mild tartar and gingivitis. H/L: NSR, NMA. Eupnic, quiet lung sounds. Abd: Soft, no pain on palpation, no masses palpated M/S/I: Left hind leg: laxity at hock, with a deep laceration on the dorsal aspect of the hock, some purulent discharge. Distal to this, the cranial aspect of the leg is covered with dark pink granulation tissue, and the plantar aspect of the leg is darkened and dry, as if the tissue is devitalized. UG: Male intact, testicles soft and symmetrical. A: 1. Wound to left hind leg – R/O fracture vs. self-trauma 2. Corneal ulceration OU Short-term prognosis: Fair Current surgery status: Temporary waiver for leg injury. P: 1. Placed light bandage on pt tonight 2.. Tomorrow, sedate for rads and better bandage placement 3. Buprenorphine 0.35 ml SQ BID x10 days 4. TAB drops BID x10 days 5. Re-evaluate eyes in 3-5 days 6. Amoxiclav 45.7 mg/ml 1.7 ml PO BID x10 days 1088
Weight 11.4

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