10/9/2018

DVM Intake Exam Estimated age: Estimated 12 weeks based on weight and dentition Microchip noted on Intake? Scanned Microchip Number (If Applicable): History : Stray kitten - walked into someone's apartment Subjective: Alert and energetic in kennel Observed Behavior - Pt looking for escape route and rushing the cat den door. When removed from den with towel, pt struggles, screams and bites through a tongue depressor. Pt was sedated for further exam. Sedated with Dexdomitor 0.07 ml IM and butorphanol 0.06 ml IM. Pt was not heavily sedated - still alert and able to run, but pt tolerated slow handling. Evidence of Cruelty seen - None Evidence of Trauma seen - None Objective BAR-H, MMs pink and moist, BCS 5/9 EENT: Eyes clear, ears clean, no nasal or ocular discharge noted Oral Exam: Adult canines and incisors. 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 mammary masses or vulvar discharge 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 Assessment: Apparently healthy Prognosis: Excellent Plan: Spay, placement SURGERY: Okay for surgery 1088

10/9/2018

Per consultation with Feline Behavior team, starting gabapentin 0.15 ml PO BID. 1088

10/15/2018

Pre-op exam BAR Clear OU/AU, nndc OP wnl PLN wnl H/L reg, no obvious murmur, ssp, lungs clear/eupenic, no c/s ABD snp MSK amb x 4 Integ wnl BCS 5/9 UG f/i Neuro a/a Rectal clean externally A:Apparently healthy P:Proceed with spay Excellent prognosis Addendum: Small 6 mm semi-deep wound left inguinal noted during spay. Wound appeared clean. Could have been from shaving belly before spay. Closed wound with burried sutures using 3-0 monocryl in intradermal pattern. Spay and recovery both were uneventful.