DVM Intake Exam
Estimated age: 4-5 months
Microchip noted on Intake? No
History : Stray. Came in as litter of 4.
Observed Behavior -Fleed and tried to scratch. Very timid. Tense body and whale eyed. Caught her in the net.
Evidence of Cruelty seen -No
Evidence of Trauma seen -No
P =240 bpm
EENT: Eyes clear, ears clean, no nasal or ocular discharge noted
Oral Exam: Clean teeth
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated
MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat
CNS: Mentation appropriate - no signs of neurologic abnormalities
Rectal: Clean externally
-Otherwise apparently healthy
-3x a day feedings
-Monitor weight and appetite
-Combo test at time of surgery
Okay for surgery (in-house and combo test)
Hx: Two littermates have URI signs. One has no signs.
S: At back of kennel, curled up with two littermates
O: No sneezing, nasal discharge, ocular discharge
A: Exposure to URI but no clinical signs at this time
P: Vitamin B12 injection, monitor
EN -- epiphora and mild blepharospasm, OU. clear nasal discharge with some crusting.
doxycycline 0.5ml PO q24h x 14 days
vitamin b12 injection 0.25ml SQ one time
BAR in kennel. Appetite is ok, not great.
EN -- conjunctivitis with mucoid ocular discharge, OU. No nasal discharge seen.
mirataz 1.5" topically q24h x 5 days
gentamycin 1 drop OU q12h x 7 days
Recheck URI day 7.
EN -- mild serous nasal discharge. sniffling
continue on current tx plan
Recheck URI day 10. BAR in kennel.
P has a good appetite.
EN -- eyes and nose are clear. no discharge or sneezing
URI -- resolved
ok to move into gen pop
BAR in kennel.
P flees into cubby when kennel approached.
EN -- blepharospasm and mucoid nasal discharge OD
Skin -- incision site clean,. dry
healing sx site
gentamycin ophthalmic drops 1 drop in right eye only, q12h x 7 days
Recheck URI relapse, conjunctivitis OD. BAR in kennel. P appears to be eating well.
EN -- mild blepharospasm and mucoid ocualr discharge OD.
continue with current tx plan
recheck in 3 days.
if no resolution in 3 days, recommend eye stain +/- change medications
Eyes wide open. No ocular or nasal discharge
removed sneeze guard.
Gabapentin 100mg/ml -- give 0.45ml PO q12h while in shelter
Moderate conjunctivitis OD, clear OS
-Recurring conjunctivitis OD only, this is the 3rd time
-Sedated with Telazol 0.15 mL IM
-Fluoro stain OD: negative
-Flushed out OD with copious amount of sterile eye wash
-Gentamycin ophthalmic drops right eye only BID x 3 days then recheck
-Move to holding where it is more quiet and less stressful for him