LEO – A1039126

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LEO – A1039126

NEUTERED MALE, WHITE, POODLE MIN / BICHON FRISE, 10 yrs
OWNER SUR – EVALUATE, HOLD RELEASED Reason PERS PROB
Intake condition UNSPECIFIE Intake Date 06/06/2015, From NY 11236, DueOut Date 06/06/2015,

Medical Behavior Evaluation BLUE
Medical Summary No Initial Exam

MEDICAL:
S/O: Patient presented as owner surrender. On presentation, patient appeared to be extremely uncomfortable with skin and ear condition.
mm = pink, moist
hydration = adequate
Integ = Severe erythema and alopecia around neck and at base of ears, bilaterally. Alopecia and lichenification of paws and distal limbs x 4 with moderate erythema and abrasions. Appeared to have a moist tan discharge between the digits. The entire ventrum appears to be thickened/lichenification with dark pigmentation. Mats around body.
EENT = Periocular alopecia and lichenification; entropion on lower lids OU; neovascularization on corneas OU; Severe amount of thick tan discharge AU, thickened and inflamed pinnae, canal is filled fur. nnd; Unable to view dentition/oral exam due to muzzle. Patient was severely uncomfortable and kept shaking head, pawing at ears throughout exam.
H/L = nma, nsr; clear lung fields bilaterally
Abdomen = snp
GU = male neutered
CNS = appropriate
MS = BCS: 6/9; amb x 4
LN = wnl
A: alopecia
lichenification
Pododermatitis x 4
Otitis externa
Entropion
Differentials include allergies/atopy vs. infectious (parasitic vs. secondary bacterial infection) vs. other
Px: Fair
P: New Hope must be notified – recommend full dermatiologic work up
Fluorescein Dye Stain – several small (approx 2 mm), round areas of uptake on the dorsal/central cornea, OS.
Gave 40,000 U/kg Pen G (1.2 mL) SQ
Gave 0.4 mL Rimadyl SQ
Gave 0.4 mL Diphenhydramine IM
Start Tramadol 25 mg PO BID x 7 days
Rimadyl 25 mg PO BID x 5 days
Benadryl 25 mg tab. PO BID x 7 days
TAB ointment (started today) – OU BID x 10 days
Start Cehalexin – 250 mg PO BID x 10 days
Consider adding Doxycycline, prophylactically.
Recheck tomorrow
Placed e-collar
Schedule for medicated bath tomorrow – no activyl applied yet.
Ear cleaning + otobiotic SID x 7 days

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