11/29/2017

DVM Intake Exam Estimated age: 3-5 years based on dentition and secondary sex characteristics Microchip noted on Intake? Scanned neg on LVT intake History : Stray, no health hx provided Subjective: Alert, sitting in litterbox. Observed Behavior - Allows all handling. Objective BAR-H, MMs pink and moist, BCS 5/9 EENT: AD cartilage is scarred and thickened. AS entire pinna is full of mattress sutures. No discharge AU. Eyes clear, no nasal or ocular discharge noted. Thick jowls. Oral Exam: Clean teeth. PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: Male intact, testicles soft and symmetrical. MSI: Distal right front leg is shaved in a circumferential pattern. Left hind leg is shaved over the medial saphenous vein and there is a small hematoma in this vein. Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat CNS: Mentation appropriate - no signs of neurologic abnormalities Rectal: Normal externally. Assessment: 1. AS suture pattern is consistent with a recent aural hematoma repair - within the last 2 weeks. 2. Right front leg is shaved in a pattern that is consistent with a recent IV catheter placement 3. Left hind leg shaved region and hematoma are consistent with a recent blood draw Prognosis: Good Plan: 1. Ivermectin 0.1 ml SQ - repeat in 10-14 days 2. Re-evaluate for suture removal in 1-3 days SURGERY: Okay for surgery 1088

11/30/2017

Hx: Aural hematoma, repaired within the last few weeks. No other noted medical problems. S: Alert, friendly, allows handling O: BAR-H, MMs pink and moist EENT: Clean ear canals; sutures throughout AS pinna, some dried discharge but no active discharge. No discharge OU, nose. H/L: Eupnic, not ausculted today Abd: Soft, nonpainful M/S/I: Amb x4, no lesions noted PLNs: None enlarged Neuro: Alert and appropriate, no sign neurological disease A: Aural hematoma, appears to have healed P: Suture removal - removed sutures from the distal half of the pinna. Remove the rest tomorrow, then remove pt from Medical. 1088

11/30/2017

Hx: Aural hematoma AS repaired - half of sutures removed yesterday. S: Alert, friendly, likes ear scratches O: BAR-H, MMs pink and moist EENT: AD cartilage is scarred and warped, so the entrance to the canal is mostly obstructed. There is moderate brown waxy discharge visible on the pinna and in the canal. AS - many sutures throughout the pinna; minimal dry crusty discharge in the canal. No discharge OU, nose. PLNs: Not significantly enlarged. H/L: NSR, NMA. Eupnic, quiet lung sounds. Abd: Soft, no pain on palpation, no masses palpated M/S/I: Amb x4. No skin lesions noted. Neuro: Alert and appropriate, no sign neurological deficiencies A: 1. AS aural hematoma - healed 2. AD scarring is preventing normal clearance of ear wax - this ear may be chronically infected Short-term prognosis: Good P: 1. Removed the remaining sutures from AS - this ear is healing well 2. Give ivermectin 0.12 ml SQ once to ensure no ear mites 3. Clean both ears gently this evening 4. No treatment needed for either ear unless there is discomfort 1088

12/7/2017

sneezed. clear OU, no nasal d/c. very social. eating food. recheck in 3 days

12/8/2017

Notes entered for 1088. Quiet in kennel today, does not want to get up from bed. Epiphora OU, mild clear mucoid nasal discharge, drooling a bit. URI - move to ISO, start doxy and cerenia. LRS 150ml SQ SID for 3 days.