DOG

A304805

Reason:

CONFISCATE

Intake Date:

Outcome:

9/5/17

EUTH

DECLARED

10/18/17

Treatment Records:

Date
Type
Medication
Weight
Description
Reason
Diagnosis
Body Condition
10/10/17
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10/10/17 : refilled Trazodone prescription; Trazodone (50 mg/tab) 100 mg PO BID x 5 days; dispensed 20 tabs
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10/2/17
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Reports from ACTs that Shy is not doing as well on his very-low-dose Trazodone protocol as he was on his regular low-dose regimen. Increase dose again to 100mg PO BID. Dispensed 28 tabs Trazodone (50mg/tab) - 2 tabs PO BID x 7d. Refill as needed to help control anxiety in shelter.
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9/25/17
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Recheck after 3 days on Trazodone for situational anxiety - appears calmer- kennel floor is drier- etc. Will try on a decreased dose to attempt to discover minimum effective dosage. Change to 1 tab (50mg/tab) Trazodone PO BID x 10d.
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9/27/17
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Flea dirt noted: treated with Capstar and topical Frontline Plus
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9/27/17
CAPSTAR
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9/27/17
FRONTLINE PLUS
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9/23/17
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ACT bathed dog today. Cleaned ears - moderately less inflammation than before treatment- and less debris. AD - still has moderate amount thick- dark brown yeasty debris; AS - still has mild-to-moderate amount medium brown ceruminous debris. Ear infection is severe and chronic- long-standing - will require chronic therapeutic management by owner. Shy has been drooling excessively during his kennel stay here- due to anxiety. Will try a short course of low-dose anxiolytic therapy to try and reduce his anxiety and help him be more comfortable. Rx Trazodone 50mg #20 - 2 tabs PO BID x 5d. Re-asses anxiety level/hypersalivation after 3-5d treatment.
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9/8/17
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09/08/17 - visual exam- noted small patch alopecia top of head and dorsal aspect of front front foot; behavior of dog prevents a more thorough exam of integument at this time.
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9/11/17
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65.9
BAR- apparently good appetite- amenable to handling and examination today. Mouth/Teeth - All teeth worn and/or filed to gumline; pytalism - appears to be chronically hypersalivating while here in kennel- probably due to stress- entire ventral neck and chest is wet. Ears - Pinnae are cropped extremely short- almost to level of head; severe- chronic otitis externa- canal of OD is almost completely occluded- copious amount of waxy-pastey dark brown exudate AU- very yeasty odor. Eyes/Nose - Mildly hyperemic sclera OU. Heart/Lung - No obvious abnormality. GI - No obvious abnormality. Reproductive - No obvious abnormality; both testes descended- bilaterally symmetrical and nonpainful; did not perform rectal exam. Skin /Hair coat - Miliary tiny patches of white hair on forelimbs and chest/neck (a typical appearance of hair regrowth after injury/scarring); superficial scars of varying ages present on forelimbs and head; very large- thick elbow calluses present bilaterally. Musculoskeletal - No obvious abnormality. Neurologic - No obvious abnormality. Dx - Severe- chronic otitis externa; suspect mixed infection- predominantly yeast. Tx - Cleaned ears. Rx for pain of severe otitis - 125mg Carprofen PO SID x 5d. Rx topical - Dermavet AU SID x 10d; clean ears q2-3d. Recommend soft bedding in kennel.
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5/9
9/11/17
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CARPROFEN TAB 100 MG
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9/11/17
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CARPROFEN TAB 25 MG
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9/11/17
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TRI-OTIC OINTMENT
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9/5/17
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Under dec review- no exam or eval needed
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9/5/17
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Administered DA2PP vaccine.
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9/5/17
DA2PP
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3/24/17
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73.4
Report from owner that Shy has an ear infection. Extremely short-cropped ears. Copious dark brown debris AU and chronically inflamed ear canals - almost occluded; difficult to clean. R ear worse than L. Multiple old scars all around face- head- neck- and forelimbs. Marked elbow calluses. All teeth are fractured and/or worn flat. Pulled several peices of wood-like material from between R upper P4 and M1 and flushed out the associated inflamed pocket of buccal gingiva opposite the lodged debris. Moderately inflamed at preputial opening - possibly from irritation from environment/floor. Cleaned ears. Administered DA2PP vaccine SQ. Rx Tresaderm otic suspension - 10 drops AU BID x 7d - first dose administered Rx Clavamox 375mg #14 and 62.5mg #14 - 1 tab of each (437.5mg per dose) PO BID x 7d - first dose administered Rx Carprofen 75mg #6 - 1 tab PO BID x 3d - first dose administered
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5/9
3/24/17
DA2PP
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3/24/17
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CLAVAMOX 375 MG
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3/24/17
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CLAVAMOX 62.5 MG
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3/24/17
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CARPROFEN TAB 75 MG
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3/27/17
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Cleaned ears - mild medium brown debris L ear; copious dark brown debris R ear + mild bleeding after repeated cleaning.
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Behavior Records:

Date
Reason
HEAD PAT
TOUCH
TOOTH
FOOD
Notes

Evaluation Records:

eval_date
eval_type
eval_comments