KING – A1034005
Safe 4-28-2015 Brooklyn
SAFE – 04/28/15
KING – A1034005
**Perianal Hernia May Need Surgery! NEEDS HELP ASAP!**
MALE, GRAY / BLACK, SILKY TERRIER, 15 yrs
OWNER SUR – ONHOLDHERE, HOLD FOR ID Reason PET HEALTH
Intake condition EXAM REQ Intake Date 04/22/2015, From NY 11434, DueOut Date 04/22/2015,
Medical Behavior Evaluation GREEN
Medical Summary scan positive: 4707266B62 intact male weight: 12.8lbs moderate dental tartar matted coat strong odor coming from anus area very matted cloudy eye lens nails were long – trimmed nails slightly tense and nervous during exam but didn’t show any signs of aggression BARH NOSF
HX: AS PER OWNER HISTORY OF ABNORMAL DEFICATION. HAS BM ONCE PER WEEK.
MINIMAL EXAM IN HALLWAY
BAR, GENERALIZED MATTING ESECIALLY AROUND FACE, SEVERE GINGIVITIS AND CALCULI, MM PINK AND MOIST, HYPERSALIVATING (WAS IN CAR), AUSCULATATION GRADE III/VI PANSYSTOLIC LEFT MURMUR
ABDOMINAL PALPATION EXTREMELY TENSE AND UNCOMFORTABLE
PUT IN FOR VC TOMOROW, RECOMMEND ABDOMINAL RADS TO RULE OUT CONSTIPATION
S/O: Vet check for poss. constipation. ACO alerted that patient had been dribbling liquid stool all day and had a strong, purulent odor.
On presentation, patient was BAR – areas of matted, unkempt coat
H/L = focal murmur ausculted on left side, grade I-II/VI; clear lung fields bilaterally.
abdomen – non-painful on palpation. Resented rectal exam. On right dorsolateral aspect of perianal region, appeared to have a large bulging mass (approx. 3 cm in diameter). On palpation, mass was soft, compressible. Rectal exam revealed a large amount of formed, light brown stool with frank blood.
LN = wnl
Shaved clumped matted regions on hind area and around eyes
Large protruding perianal mass – r/o perineal hernia vs. constipation/obstipated vs. neoplasia vs. anal gland abscess vs. other
Patient required light sedation for radiographs – due to heart murmur and age, used Hydromorphone – 0.14 mL SQ and Diazepam – 0.28 mL IV.
2 view abdominal radiographs revealed an intact bladder, and loops of intestines – no evidence of herniation; descended colon filled with mildly opaque and gritty material (feces), which seemed to accumulate at the distal colon, just before the anus (where the mass protruded).
Manual deobstipation performed – patient required further sedation – used 0.25 mL Dexdomitor IV
Large amount of firm yellow/brown stool with frank blood was emptied from the large colonic “sac” on the right side. Continued to empty colon – milked out feces from proximal descending colon. No punctures could be palpated in the colon. No obvious herniation present. Gave butt bath.
Patient was given 0.25 mL Antisedan IM – recovered uneventfully.
Full blood work taken:
leukocytosis consisting of a neutrophilia with a left shift and a monocytosis
Mild normocytic normochromic regnerative anemia
Start course of Rimadyl – 12.5 mg PO BID x 5 days – gave 0.25 mL Rimadyl SQ once at 6 PM
Miralax – 8.5 g sprinkled in food PO x 5 days. – reassess quantity (stool consistency) tomorrow.
Continue to monitor stool and protrusion.
S/O: Patient ate very well overnight. Kept in medical recovery for observation. This morning, small amount of soft stool located in back of cage. Patient is BAR. Urinated on blanket.
Dr. 0844 palpated rectum together. Rectal sacculation is still present. moderate amount of anal tissue swelling. Small amount of feces present within the rectum.
1. Continue current treatment plan and monitor
S/O: Vet check to monitor Perianal hernia. This morning, patient remains BAR.
Patient allowed gentle palpation of anal area
Moderate amount of peri-anal tissue swelling, however appears somewhat reduced
Unable to externally palpate compressible stool in region of previous protrusion.
Area feels very soft to touch.
A: Good to excellent with approrpriate surgical correction
COntinue to monitor, recheck tomorrow
Hx: Vet check to monitor perineal hernia.
O: Pt tolerated gentle palpation of anal area. Pt also allowed digital rectal exam although he vocalized and moved away. There is a moderate amount of peri-anal tissue swelling, primarily on the right side. The swelling is reduced from the size at initial exam. The area is soft and when squeezed, a small amount of loose thick diarrhea was extruded – brown with a small tinge of red.
1. Perineal hernia, stable with stool softener and analgesics, appears to be shrinking with softer stool and no straining.
Short-term prognosis: good to excellent. Will definitely require long-term follow-up care, may require surgical management.
1. Continue Rimadyl until course finished
2. Continue stool softeners until definitively managed
3. Continue to monitor, recheck q2 days
Basic Information: King is an unaltered silky terrier. He was bought from a pet store as puppy and is being surrender because he has troubled defecating.
Social Life and Personality: King has been around children aged from infants and older. He is relaxed around children and gentle during play. He has lived with another dog and is relaxed and tolerant of the other dog. He has been around cats and i respectful of the cat. King is house trained and rarely has accidents inside the home.
Behavior: King is not bothered when people touch his food, remove a treat or bone, when bathed, held brushed, or when strangers approach his home or family.
For a New Family to Know: King is used to slow walks on a leash three times a day. He is well behaved when home along. He eats wet and dry food. His favorite treats are rawhides. He likes to sleep in bed.
Intake Behavior: King had a soft body. When approached and solicited attention. He allowed handling attention and did not show aggressive behaviors.
PLAYGROUP BEHAVIOR: When off leash with other dogs, King is interested in interacting with other dogs but mostly explores the yard.
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