10/2/2018

DVM Intake Exam Estimated age: ~5weeks based on PE. Microchip noted on Intake? scanned negative; placed by LVT History : stray Subjective / Observed Behavior - BAR; allows all handling. Evidence of Cruelty seen - none Evidence of Trauma seen - none Objective BCS 5/9 EENT: Eyes have mucoid discharge; ears clean, mild clear nasal discharge Oral Exam: normal kitten dentition PLN: No enlargements noted H/L: No murmur ausculted; CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: intact male. MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat CNS: Mentation appropriate - no signs of neurologic abnormalities Rectal: grossly normal. Assessment URI, mild -- suspect viral conjunctivitis Prognosis: good. Plan: vitamin b12 injection 0.1ml SQ one time fortiflora q24h x 5 days gentamycin ophthalmic ointment q12h x 5 days SURGERY: Temporary waiver due to age

10/8/2018

History : Out in foster, returned because foster noted a bump on head that this morning ruptured. It was bloody and pus filled. Subjective: BAR, friendly Observed Behavior - friendly, okay for medical handling Evidence of Cruelty seen - n Evidence of Trauma seen - n Objective T = NT P = 200 R = 24 BCS 5/9 EENT: mucopurulent oculonasal discharge noted, congested , ears clean, Oral Exam: decidious teeth, no oral ulcers noted PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: male MSI: Ambulatory x 4, skin free of parasites, healthy hair coat, two puncture wounds on midline of frontal bone, blood tinge discharge noted CNS: Mentation appropriate - no signs of neurologic abnormalities Rectal: Assessment - two puncture wounds on head r/o bite wound vs. trama - mucoid-purulent oculonasal discharge r/o URI Prognosis: fair Plan: - Give 0.02mg/kg of Buprenex SL (0.04 ml) - Flush wound with saline - Start clavamox 13.75 mg/kg PO BID - recheck in 3 days SURGERY: Temporary waiver due to age

10/11/2018

SO recheck wound along top of head. Skin -- wounds are healing. no swelling. healthy crusts along both puncture sites. non painful on palpation A wound of unknown origin P continue on current tx plan