ROSE – A1109729
Safe - 4-23-2017 Manhattan
SAFE 4/23/17 Rose has severe dermatitis possibly caused by fleas or food – also has some ringworm lesions – needs treatment asap – 4 years old and friendly.
ROSE – A1109729
MALE, WHITE, DOMESTIC MH MIX,4 yrs
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition ILLNESS Intake Date 04/22/2017, From NY 10009, DueOut Date 04/25/2017,
Medical Behavior Evaluation BLUE
Medical Summary DVM Intake Exam Estimated age: 4years Microchip noted on Intake? 981020021204278 History : brought in as a stray Subjective: BAR Observed Behavior – was initially good for exam but quickly became fractious; does not like being scruffed or restrained Evidence of Cruelty seen – severe diffuse dermatitis/ulceration Evidence of Trauma seen – none Objective T =not taken P = WNL R =WNL BCS 4/9 EENT: OU-periocular alopecia and mild erythema with mucoid discharge-appears to be coming from skin AU-copious amount of brown discharge no nasal d/c Oral Exam: mm pk, moist; CRT <2 sec; moderate staining and gingival recession around canines, severe calculi build up on premolars PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G:unable to palpate scrotum due to temperament MSI: ambulatory x 4 with no evidence of orthopedic disease severe diffuse moth eaten alopecia, crusting and ulceration around head and extending over dorsum to tail-wood’s lamp positive on several lesions on head; mild moth eaten alopecia over paws no obvious fleas or flea debris CNS: mentation appropriate – no signs of neurologic abnormalities Rectal: not performed Assessment 1. Diffuse, severe dermatitis-r/o atopy vs flea allergy vs food allergy vs ringworm vs other 2. Ringworm-suspect secondary condition to underlying dermatitis 3. periocular dermatitis 4. ear mites Plan convenia terbinafine 95 mg PO SID x 4 weeks, then re-evaluate TAB ointment OU SID x 7 days flush ears, tresaderm x 10 days rec’d dental with poss extractions Prognosis: good pending response to treatment; suspect severe allergic dermatitis with compounding ringworm; ringworm lesion appear localized to a few spots on top of head-if not resolving with systemic therapy, then will require lime sulfure dips SURGERY: Temporary waiver due to ringworm/dermatitis
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View all entries in: Safe Cats 2017-04