WOOFY – A1104859
Safe -
3-2-2017 Manhattan
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SAFE 03/02/17
WOOFY – A1104859
NEUTERED MALE, BROWN, CHIHUAHUA SH MIX, 8 yrs
OWNER SUR – EVALUATE, NO HOLD Reason NEW BABY
Intake condition UNSPECIFIE Intake Date 02/27/2017, From NY 10453, DueOut Date 02/27/2017,
Medical Behavior Evaluation GREEN
Medical Summary Sex: Male neutered, Scan: Negative. Estimated age: Reported to be 8 years. Fleas: No flea dirt. Hx: Started losing his fur a few months ago – has been getting worse over time. S: Quiet, timid, doesn’t move much but body is not tense, allows all handling. O: BAR, decreased skin turgor, estimated 5% dehydrated, BCS 3/9, MMs pink and moist, CRT <2 sec. EENT: Mild serous nasal discharge. Most of head (and body) is alopecic, hyperkeratotic and lichenified with mild crusting – most severe on ears and ventral neck. Ear canals are stenotic with moderate waxy and slightly wet discharge – AD worse than AS. Mild tartar. Eyes are clean. 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. All of body besides a 4-5 inch column of fur surrounding the dorsal spine is alopecic, hyperkeratotic, lichenified, with mild crusting. Multiple small abrasions around the shoulders. UG: Male neutered. Skin scrape – negative for Demodex mites.
A:
1. Severe alopecia, hyperkeratosis – R/O severe allergies vs. endocrine disease vs. alopecia X vs. nutritional deficiency vs. liver dz. vs. other
2. Otitis externa – R/O same root cause as dermatitisShort-term prognosis: Good-fair
P:
1. Bathe every other day with malaseb shampoo x2 weeks, ideally this would be followed by daily application of an antiseptic lotion
2. CBC/chemistry overnight
3. Clavamox 62.5 mg PO BID x21+ days
4. Clean ears q3 days, apply Otibiotic AU BID x10+ days
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