SHADOW – A1034865
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SAFE – 05/06/15
SHADOW – A1034865
***RUPTURED LEFT EYE & HEMATOMA IN EAR. NEEDS VET CARE! ****
NEUTERED MALE, BLACK, LABRADOR RETR, 12 yrs
STRAY – EVALUATE, NO HOLD Reason OWNER DIED
Intake condition UNSPECIFIE Intake Date 04/30/2015, From NY 11101, DueOut Date ,
Medical Behavior Evaluation BLUE
Medical Summary SCANNED NEGATIVE MALE NEUTERED 12 YEARS OLD ~ EETN-LEFT EYE RUPTURED AND LEFT EAR HEMATOMA WITH STICHES IN -SEVERE GINGIVITIS SKIN-NO FLEAS NOTED (ACTIVYL APPLIED) SLOW WALK AND DRAGGING RIGHT HIND LEG BARH
A shelter staff member writes:
Shadow was surrendered because his owners passed away. He is a friendly 12 year old boy looking for a loving new home. He has a mass in his left eye and may need an enucleation. He has a hematoma in his ear, which was once repaired, but has not recovered fully. Please help sweet Shadow get the vet care he needs and deserves. Pull him from BACC!
Hx: Surrendered today, reported to have tumor in eye and aural hematoma
S: Quiet, tolerant of most handling although resists when mouth is examined, walks slowly, shakes head often
O: QAR-H, BCS 4/9, muscle wasting over hips and hind legs, MMs pink and moist, CRT <2 sec
EENT: Pedunculated pigmented mass (1 cm dia) hanging from left globe. The visible tissue dorsal to the tumor is pink and vascular as if conjunctiva. No discharge OS. OD: cataract, otherwise WNL.
AS: Moderate dark waxy discharge, stenotic canal, aural hematoma with sutures through all layers of ear as if recent surgery; small amounts of hemorrhagic fluid are draining from some suture holes, pinna is thickened and lumpy, firm in some areas, soft in others. There are large dry brown crusts encasing the distal half of the pinna and the sutures, more severe on medial aspect than on lateral aspect. Tympanum not visualized.
AD: Severe dark waxy discharge, small (~1.5×3 cm) soft hematoma in pinna. Tympanum not visualized.
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. No lesions noted.
UG: Male neutered
Neuro: Scuffs left hind foot when walking, no response to knuckling. Right hind foot: appropriate response to knuckling test.
1. Left eye mass – R/O benign vs. malignant, already spread vs. contained in globe
2. Left ear – chronic aural hematoma and otitis externa. Hematoma was surgically repaired at one point but is not resolved
3. Right ear – otitis externa, recent aural hematoma
4. Proprioceptive deficits in left hind leg – R/O effect of aging
5. Cataract OD
Short-term prognosis: Fair with appropriate treatment
1. Cleaned both ears and started Otibiotic – continue Otibiotic AU BID x10 days
2. Baytril 136 mg tabs, 1.5 tabs PO SID x10 days for ear infection
3. Clavamox 375 mg BID x 10 days
3. Clean ears and pinnae daily x5 days, then EOD for 3 tx (6 days)
4. Ideally, pt needs ultrasound of left eye and enucleation or extenteration, plus definitive treatment of both ears including likely culture and extended treatment of otitis, with aural hematoma lancing (AD) and possibly revision surgery (AS). No tx needed for pt’s neurological deficits besides monitoring and physical support.
Shadow is an older neutered black lab. He is being surrendered because his owner’s passed away.
The surrender states that he knows Shadow is very tolerant of young children and gentle during play with them. He has lived with a cat and is affectionate with the cat. He is friendly with dogs he meets as well.
The surrender says that Shadow has never growled or snapped at anybody for any reason. He is not bothered when people take away his food bowl, bones, or treats. He has a low activity level and doesn’t play too much anymore. The surrender says that he loves to be pet.
Shadow was relaxed during the intake and was lying down throughout the intake. He allowed handling and did not show aggressive behaviors. He wagged his tail when spoke to and pet.
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