WITCHIE – A1118775 

WITCHIE – A1118775

*** NEEDS FOLLOW UP VET CARE ASAP ***

NEUTERED MALE, GRAY, POODLE MIN / SHIH TZU, 8 yrs
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition EXAM REQ Intake Date 07/17/2017, From NY 10456, DueOut Date 07/20/2017,

Initial Exam (7/17/17)

DVM Intake Exam Estimated age: 7-10 years based on dentition and overall condition Microchip noted on Intake?   Scanned neg History :  Stray, no health hx givenSubjective: BAR, stands in place for exam and wags tail constantly, allows all handling. Objective  Estimated 10% dehydrated – severely decreased skin turgor, sunken eyes.T =                             P =   R =  16  BCS 3/9. EENT:  Eyes clear, ears clean. Severe mucopurulent nasal discharge. Oral Exam:  Severe tartar, gingivitis and gingival recession. Canine teeth are all tilted out of the mouth. Swelling on right side of maxilla, in alveolar mucosa, with a large fistula pointing towards the nasal cavity. There is a small, firm, movable nodule at the center of the fistula, possibly a tooth. There is bright red clotted blood attached to the right lower and upper lips, and fresh blood dripping from this side of the mouth. Severe halitosis – smells like a severe infection.

H/L:  Grade 2/6 systolic heart murmur, PMI left apex. NSR.   Marked inspiratory and expiratory upper airway sounds. Increased resp effort, abdominal breathing.

ABD:  Non painful, no masses palpated

U/G:  Male neutered

MSI:  Alopecia ventral abdomen. Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat

CNS:  mentation appropriate – no signs of neurologic abnormalities

Rectal:  Normal externally

Assessment:

1. Severe dental infection with oronasal fistula, intraoral bleeding – likely secondary to severe dental disease. Infection is causing swelling which is causing resp distress.
2. Dehydration
3. Underweight – likely difficult to eat due to oral pain
4. Heart murmur

Plan:

1. Dexamethasone 2 mg/ml 0.4 ml IM tonight
2. Amoxiclav 2.5 ml PO BID x10 days
3. Baytril 100 mg/ml 0.5 ml PO SID x10 days
4. LRS 300 ml SQ SID x5 days
5. Simbadol 1 ml SQ SID x5 days
6. Pt needs CT or skull rads and dental cleaning ASAP

Prognosis: Good with immediate treatment

Meet Witchie: This handsome fellow is full of wags and smiles!  He has severe dental disease and will need a CT scan or skull rads and a dental cleaning as soon as possible.  Witchie should go to a vet hospital first thing tomorrow.  Please help this handsome, friendly pup today!

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