1/15/2020

DVM Intake Exam Estimated age: Approx 6 years Microchip noted on Intake? Negative History: Stray Subjective: QARH, hunched and frozen for entire exam, pupils dilated, does not react to any handling. Evidence of Cruelty seen - no Evidence of Trauma seen - no Objective P = wnl R = wnl BCS = 7/9 EENT: Eyes clear, ears clean, no nasal or ocular discharge noted Oral Exam: Mild staining, adult dentition PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: Male neutered MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat, one claw grown into paw pad on each front paw CNS: Mentation appropriate - no signs of neurologic abnormalities Rectal: Externally normal Assessment: Ingrown claws x 2 (front paws) with paw pad wounds Overweight Prognosis: Good Plan: Clipped all nails, cleaned paw pad wounds (from ingrown nails) with chlorhex Onsior 2 mg/kg given SQ once Recheck paw pad wounds in 3 days CTM while at BACC

1/18/2020

Hx: 1/15/2020 Intake- Stray, embedded overgrown nails into paw pads with wounds, overweight. Clipped nails and cleaned paw pad wounds with chlorhexadine. Given onsior once. Today, 1/18- Progress exam, recheck embedded nails SO: BARH, no c/s/v/d. E/d well, well formed stool noted in litter box. Very nervous and tense, hidden in back of kennel. Hissing and swatting when approached, toweled for exam and somewhat tolerate handling this way. P = wnl R = wnl BCS = 7/9 EENT: No ocular/nasal discharge. Ears clear of debris/cerumen. Oral Exam: adult dentition, mild dental plaque/staining noted, mild gingivial inflammation, no oral lesions. MM pin, moist, CRT <2s. PLN: No enlargements noted H/L: No murmurs or arrythmias ausculted. Normal BV sounds no crackles or wheezes. ABD: Soft, non painful, no masses palpated U/G: MN, no discharge MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat, short nails, 2 embedded nails into paw pads healed, appropriate granulation tissue noted. No swelling or discharge noted. CNS: Mentation appropriate - no signs of neurologic abnormalities Rectal: Not performed, externally normal A: Overweight Stage I dental disease Embedded nails into paw pads with wounds (resolved) P: CTM while at BACC Recommend dental scaling/polish + weightloss with placement

1/19/2020

Starting gabapentin 20 mg/kg PO q12h indefinitely for shelter anxiety

Upon Intake, Shipok was vocal upon approach and allowed counselor to collar. Shipok allowed counselor to scan for a microchip and pick up to transfer into a hard carrier. Shipok only meowed throughout the intake when he was interacted with but he did not hiss, swat, or bite.