CALVA – A1056918
Safe 11-5-2015 Brooklyn
CALVA – A1056918 SPAYED FEMALE, WHITE, SHIH TZU MIX, 10 yrs STRAY – EVALUATE, HOLD RELEASED Reason STRAY Intake condition EXAM REQ Intake Date 11/04/2015, From NY 11420, DueOut Date 11/07/2015 Medical Behavior Evaluation GREEN Medical Summary Scan: negative Spayed Approx 10 yr S/O: BAR, APP ++, friendly EENM: MM pink, moist, dental disease grade […]
CALVA – A1056918
SPAYED FEMALE, WHITE, SHIH TZU MIX, 10 yrs
STRAY – EVALUATE, HOLD RELEASED Reason STRAY
Intake condition EXAM REQ Intake Date 11/04/2015, From NY 11420, DueOut Date 11/07/2015
Medical Behavior Evaluation GREEN
Medical Summary Scan: negative Spayed Approx 10 yr S/O: BAR, APP ++, friendly EENM: MM pink, moist, dental disease grade 3/4, many missing teeth. CV: NO MURMURS OR ARRHYTHMIAS LUNGS: Increased BV sounds (harsh sounds) ABD: Distension, hepatomegaly MS/INTEG: Severely matted, and severe dorsal dermatitis w/ scale and hyperpigmentation, generalized thin fragile skin, multifocal areas of ulcerations. Lower extremitites have erythema, moist dermatitis. Small upper eyelid mass on Right upper eyelid, Three other 1cm cutaneous masses, one on right side of face, dorsal neck. 2cm ulcerated pedunculated mass on tail. Toe nails were very long and curled under. Matting was extremely thick and caked w/ urine and feces AMB X 4, BCS 5/9 NS: Appropriate mentation PLN: All LNs palpate normally GU: Vulva was matted over, perivulvar dermatitis GI: Diarrhea Thoracic radiographs reveal moderate bronchointerstitial pattern, suspect enlarged cardiac sillouette, inceased sternal contact however positioning was not ideal. Early heart failure cannot be ruled out. Abdominal radiograhs revealed hepatomegaly and calcified renal pelvis. A: Suspect severe dermatitis and pyoderma due to severe matting and underlying endocrinopathy (Ddx Cushing’s disease, hypothyroidism, etc) P: Start clavamox and buprenorphine, recommend placement w/ rescue group and follow-up veterinary for general minimum database and opthalmic minimum database.
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