11/7/2018

[DVM Intake] DVM Intake Exam Estimated age: 9 years Microchip noted on Intake? Microchip Number (If Applicable): History : Subjective: BAR Observed Behavior -Friendly, allows all handling Evidence of Cruelty seen -No Evidence of Trauma seen -No Objective T = P =120 bpm R =eup BCS 4/9, generalized muscle wasting EENT: Mild to moderate conjunctivitis OU, mild to moderate debris and erythema AU, no nasal or ocular discharge noted Oral Exam: 2-3/4 PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic, no c/s,no crackles or wheezes, looks like had abdominal component to breathing but lungs sound normal ABD: Non painful, no masses palpated U/G: M/I, both down MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat CNS: Mentation appropriate - no signs of neurologic abnormalities Rectal: CLean externally Assessment: Conjunctivitis OU Otitis externa AU Neutrophila (very mild)-r/o stress vs. infection vs. inflammation Thrombocytopenia with normal scattogram-suspect lab error and clumping Elevated ALP (very mild,3 pts only)-r/o age vs. hormonal vs. liver dz less likely (all other liver values wnl) Prognosis: Fair to good Plan: Cleaned ears AU Applied Claro AU Recheck ears in 7 days Shirmer tear test: both eyes wnl, > or equal to 15 mm/min Start neopolydex both eyes BID x 7 days then recheck CBC/chem CAXR LVT to give Convenia 8 mg/kg SQ for possible infection Recommend recheck blood work once placed just to make sure everything stable, not getting worse but not concerned, overall looks great for older dog SURGERY: Okay for surgery

11/7/2018

CAXR: Chest: Heart wnl, trachea wnl, pulmonary vessels wnl, mild to moderate bronchointerstitial lung pattern (r/o normal for old dog vs. bronchitis vs. infection vs. other) Abdomen: Large amount of ingesta in stomach and slightly distended, some gas and fluid in intestines, mineral opacity located around the level of the right kidney vs. in small intestines overlying right kidney (r/o ingesta vs. kidney stone), multiple mineral opacities throughout intestines (likely ingesta vs. fb vs. other), spleen looks mildly enlarged otherwise wnl Conclusion: 1:Mineral opacities throughout small intestines (suspect ingesta) 2:+/- mineral opacity in right kidney vs. suspect more likely in small intestine 3:Distended stomach with ingesta 4:Bronchointerstitial pattern in lungs-likely normal for his age 5:Mild splenomegaly Nothing concerning on x-rays

11/7/2018

CBC: 1-Neutrophilia (mild)-r/o stress vs. infection vs. inflammation 2-Monocytosis-r/o chronic infection/inflammation 3-Thrombocytopenia with normal scattogram-suspect lab error due to clumping Chemistry: 1-Elevated ALP (very mild, only 3 points)-r/o age vs. hormonal vs. liver dz less likely (all other liver values wnl) Otherwise chemistry wnl

11/9/2018

SO One episode of reported soft stool within the kennel. BAR in kennel. P is standing at front of kennel. Symptoms board also indicates P did not eat on 11/9 EN -- eyes and nose are clear. No discharge seen. A one episode soft stool -- r/o early CIRDC, dietary, stress P continue to monitor in shelter. no tx at this time.

Upon intake, Toby had a loose body and approached me right away and allowed me to pet him and collar him. Once on the leash, Toby paced back and forth and pulled hard on the leash. Toby walked well on the leash and allowed me to place him into his kennel. Once inside, Toby began to bark and pace back and forth.