ZOEY – A1101622

ZOEY – A1101622

FEMALE, TAN / BLACK, YORKSHIRE TERR / CHIHUAHUA LH, 5 yrs
OWNER SUR – EVALUATE, NO HOLD Reason TOO MANY P
Intake condition INJ MINOR Intake Date 01/15/2017, From NY 11207, DueOut Date 01/15/2017,

Medical Behavior Evaluation GREEN
Medical Summary 01/15/17 Microchip scan neg. O: QARH. mm=lt pink, moist, CRT<2 s. Calm, friendly, allows all handling (including of injured side of her face). ORAL: Mild to mod. calculus, gingivitis. EENT: OD – WNL. AD – WNL. OS – entire eye crusted over, unable to visualize or palpate globe. AS – Severe purulent discharge, large amount of debris and discharge covering pinna and matted into fur. H/L: HR=92, RR=16. Lungs clear. No murmurs/arrhythmias. ABD/UG: Palpation WNL. Female, no spay scar found. MS: Amb x 4. Good body condition. INTEG: Left side of muzzle and face covered in purulent discharge and crusted debris, fur is matted.Skin that is visible is erythematous. No maggots seen. Matted haircoat. Overgrown nails. A: Severe otitis externa AS, severe pyoderma left side of face. Not clear if eye is present or ruptured. P: Hydromorphone 2 mg/ml 0.28 ml SQ given. Convenia 80 mg/ml 0.28 ml given. Sedated with Dexdomitor 0.12 ml IV. Gently removed debris from OS with warm water – eye is present and intact. Mild corneal edema, mod. conjunctival hyperemia and chemosis. Has a periocular wound with erythema and purulent discharge. Shaved all fur away from left side of face and left ear. Has an irregular 1 cm open wound over left zygomatic arch, draining serosanguineous fluid. Otoscopic exam AS – mod. canal swelling, purulent discharge. Tympanum appears intact. Cleaned wounds with chlorhexidene and applied Silvidene cream. Cleaned AS, applied Mometamax. Shaved all other mats from body and limbs. Antisedan 0.12 ml IM to reverse sedation. Place e-collar 10 cm to prevent self trauma to face. Start Baytril 68 mg 0.25 tab PO q 24 hours x 2 weeks. Start Rimadyl 25 mg 0.5 tab PO q 24 hours x 7 days. Clean wounds on face and apply SSD cream q 24 hours x 5 days. Apply Mometamax AS q 24 hours x 7 days then recheck ear to assess if needs a longer course. Apply Ciprofloxacin opthalmic drops OS BID x 7 days. Excellent prognosis with appropriate management.
Weight 6.1

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