12/7/2017

DVM Intake Exam Estimated age: 2 years based on dentition and overall size Microchip noted on Intake? Scanned neg - MC placed during exam History : Stray, no health hx available. Subjective: Alert, calm Observed Behavior - Slightly tense but allows all handling; no stress even with blood draw Evidence of Trauma seen - Distal tail is missing Objective BCS 6/9, MMs pink and moist, BAR-H EENT: Eyes clear, ears clean, no nasal or ocular discharge noted Oral Exam: Mild tartar PLN: No enlargements noted H/L: NSR, NMA, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: Female, appears intact based on very small amount of mammary development MSI: Ambulatory x 4, one live flea and copious flea dirt noted. No masses noted, healthy hair coat except for distal tail which is missing - the distal 8-10 cm is missing, and the distal-most 8-10 cm of remaining tail is alopecic and the skin is thickened and peeling slightly as if scarred. The skin is fully healed, however; there is no exposed SQ tissue. CNS: Mentation appropriate - no signs of neurologic abnormalities Rectal: Normal externally Assessment: 1. Fleas - administered Paradefense 2. Tail trauma - appears to have been several months ago and the remaining tail has healed appropriately. The fur will likely grow back over time. Prognosis: Good Plan: No treatment needed at this time SURGERY: Okay for surgery 1088

12/13/2017

S/O -QAR -no obvious appetite this morning -soft sneezing, sniffling, mild serous nasal discharge -OU: open and clear -appears eupnic A URI P move to isolation doxycycline 0.8 ml PO SID x 10 days cerenia 0.4 ml SQ SID x 2 days nebulize SID x 4 days

Maple was brought in finder's book bag and was placed on top of and was placed out on top of computer desk during intake. Maple sat down and allowed me to pet her and hold her to stop her from walking away. Maple allowed me to collar her and pick her up but struggled a little when being put into a carrier. Her body would become stiff and she would push away from the carrier.