DVM Intake Exam
Estimated age: Estimated 5-10 years based on dentition
Microchip noted on Intake? Scanned negative
History: Police intake, no health hx provided
Subjective: Alert in kennel
Observed Behavior - Hissed when approached in the kennel. Growled and hissed throughout exam, but tolerated exam with a slow approach. Biting at towel during vaccinations, and tech treatments were cut short due to biting and trying to escape.
Evidence of Cruelty seen - None
Evidence of Trauma seen - None
BAR-H, MMs pink and moist, BCS 7/9
EENT: Eyes clear, ears clean, no nasal or ocular discharge noted
Oral Exam: Tartar, stage 2/4 periodontitis
PLN: No enlargements noted
H/L: NSR, NMA, Lungs clear, eupnic, no coughing or sneezing
ABD: Non painful, no masses palpated, not distended
U/G: Female, no vulvar discharge or mammary masses, unable to check for spay scar due to behavior
MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat
CNS: Mentation appropriate - no signs of neurologic abnormalities
Rectal: Normal externally
Wood's Lamp Exam: N/A
Assessment: Overweight, dental disease
1. Recommend weight loss of 1-3 lbs
2. Recommend dental cleaning and daily tooth brushing
Okay for surgery
Gabapentin extension due to stress in shelter:
Gabapentin 0.9 ml PO BID
Surgery report - feline spay
Was this cat in heat, pregnant or have a pyometra? Pt had one large ovarian cyst on each ovary, and there was mild uterine thickening and fluid distension.
Ventral Midline Incision
Ovaries Ligated with: Pedicle ties
Uterine Body Ligated with: 3-0 PDS in 2 modified Miller's knots
Abdominal Closure: 3-0 PDS. Linea - single cruciate stitch. Skin - single intradermal stitch.
Green Linear Tattoo Placed near Midline
S: Meows, at front of kennel, soliciting attention
O: BAR-H, BCS 5/9, MMs pink and moist
EENT: AU mild granular discharge. No discharge OU, nose. Stage 2/4 periodontitis.
PLNs: Not significantly enlarged.
H/L: NSR, NMA. Eupnic, quiet lung sounds. No coughing or sneezing.
Abd: Slightly tense/big abdomen.
M/S/I: Polydactyl front feet. Amb x4. No skin lesions noted.
UG: Female, no vulvar discharge or mammary masses.
Neuro: Alert and appropriate, no sign neurological deficiencies
A: Suspect ear mites
P: Spay today, give ivermectin 0.1 ml SQ - repeat in 10-14 days
sedated 0.2cc telazol IM for slight embedded nail located in left hind foot- cleaned with chlorhexidine scrub, seen by Dr 1379.
MC, and combo test completed.
Anesthesia Summary – Feline OHE
Butorphanol 10mg/mL injectable,0.08 mL IM
Dexdomitor 0.5mg/mL injectable, 0.08 mL IM
Ketamine 100mg/mL injectable, 0.08 mL IM
Propofol 10 mg/ml, injectable 1.60 ml IV
Size 4 fr. ET tube placed, maintained general anesthesia throughout procedure on isoflurane and O2. Used non-rebreathing system with 0.5 L bag.
22 g IVC placed in R cephalic vessel.
Intraoperative IV LRS at 5-10mL/kg/hr: 40 mL/hr
Perioperative pain medications:
Simbadol 1.8mg/mL injectable, 0.55 mL SQ, given pre-post-operatively.
Robenacoxib (Onsior) 20mg/mL injectable, 0.41 mL, SQ, given pre/post operatively.
Reversed with Antisedan 0.04 ml IM after sx.
Local Block Peritoneal:
Lidocaine (0.2 mL), administered pre-operatively.
Post-operative Medications Prescribed:
Simbadol 1.8mg/mL injectable, 0.55 mL, SQ, once a day for 2 days beginning the day after surgery.
Onsior 20mg/mL injectable, 0.41 mL, SQ, once a day for 2 days beginning the day after surgery.
Surgical Monitor: 1554