10/10/2018

DVM Intake Exam Estimated age: ~12+ years based on PE. Microchip noted on Intake? scanned negative. Placed by LVT History: stray that was surrendered by the caretaker of the owner. Subjective / Observed Behavior - BAR; allows all handling. very friendly. Evidence of Cruelty seen - none Evidence of Trauma seen - none Objective BCS 6/9 EENT: Eyes have advanced cataracts, OU; ears have mild exudate with moderate stenosis and erythema of the pinnae. no nasal or ocular discharge noted. sneezed but only after muzzle placed. Oral Exam: dc 4/5; pd 4/5 PLN: No enlargements noted H/L: No murmur ausculted; CRT < 2, Lungs clear but difficult to auscult due to moderate amount of upper airway noise. ABD: Non painful, no masses palpated within abdomen. ~3inch left inguinal hernia palpated. non reducible. U/G: intact female. no mammary masses palpated MSI: Ambulatory x 4, skin free of parasites, healthy hair coat; multiple (3) 0.5cm masses dermal pink, non-haired masses throughout the body (dorsum and L distal pinna) CNS: Mentation appropriate - no signs of neurologic abnormalities Rectal: grossly normal. Assessment geriatric slightly overweight severe dental disease inguinal hernia dermal masses advanced cataracts otitis externa upper airway noise r/o tracheal collapse Prognosis: fair Plan: ear cleaning gentizol -- 4 drops q12h x 7 days, AU SURGERY:Permanent waiver due to age

10/12/2018

S: Alert, at front of kennel O: Cataracts, inguinal hernia visible -Audible upper airway noise, occasional sniffling -Nose wet and occasionally dripping A: Appears to be developing CIRDC P: Doxycycline 50 mg PO SID x14 days Cerenia 8 mg PO SID x4 days Enrofloxacin 45.4 mg PO SID x14 days 1088