7/24/2019

DVM Intake Exam Estimated age: Estimated 3-5 years based on dentition and overall appearance Microchip noted on Intake? Scanned negative History : Came from house with many cats. One cat is FeLV-pos and many have URIs. Subjective: Calm, walks around exam table Observed Behavior - Slightly tense, allows all handling without fleeing Evidence of Cruelty seen - Possibly neglect Evidence of Trauma seen - None Objective BAR-H, MMs pink and moist, BCS 4/9 EENT: OU conjunctival erythema, epiphora. AU mod-severe black discharge. Mild mucoid nasal discharge. Oral Exam: Stage 2-3/4 periodontitis PLN: No enlargements noted H/L: NSR, NMA, Lungs clear, eupnic, no coughing or sneezing ABD: Soft, non painful, no masses palpated, not distended U/G: Male intact, testicles S/S MSI: Tail and flanks have feces stuck to them. Ambulatory x 4, skin free of parasites, no masses noted. CNS: Mentation appropriate - no signs of neurologic abnormalities Rectal: Normal externally FeLV/FIV test: FIV-pos Assessment: 1. FIV 2. URI 3. Likely ear mites Prognosis: Good Plan: 1. Vitamin B12 injection 2. Doxycycline 0.8 ml PO SID x7 days 3. Cleaned ears and instilled Tresaderm AU - repeat SID x4 more days 4. Ivermectin 0.1 ml SQ today and repeat in 10-14 days 5. Brush/groom SURGERY: Temporary waiver due to URI 1088

7/24/2019

[Spay/Neuter Waiver - Upper Respiratory Illness] Your newly adopted animal is in treatment for an upper respiratory illness. The veterinarian is temporarily waiving this animal from the spay/neuter requirements of the City of NY until such time as the illness has resolved and the pet has sufficiently recovered. At that time, this animal must come into compliance with the spay/neuter requirements.

7/30/2019

SO Recheck URI day 7. BAR in kennel. EN -- eyes are clear. sneezing, slight audible congestion A URI P nebulization q24h x 5 days extend doxycycline 0.9ml PO q24h x 10 days

8/3/2019

SO: On treatment for moderate URI in iso eating well. BAR in kennel moderate nasal congestion A: URI improving P: continue doxycycline addition of little remedies 1 drop each nostril BID x3d

8/13/2019

Hx: has had URI; FIV (+) q- bar eent- oral pain; difficult to assess oral cavity eating some A) FIV resolved URI but has oral pain most likely from dental disease (cannot assess oral cavity completely without sedation) Stomatitis/gingivitis causing secondary oral pain P) rec'd dental treatment and full oral exam

8/14/2019

HX Problem List: dental disease oral pain concerned about gingivitis and stomatitis FIV (+) h/o uri EENT- oral pain and gingivitis; limited oral exam due to pain A) FIV + oral cavity inflammation P) move out of ISO monitor appetite closely consider sedation and oral exam needs dental rx

8/16/2019

Cat Neuter Was this cat a Cryptorchid? no If so, describe surgical process: n/a Routine Feline Neuter seminiferous and vascular portions of cord separated and tied in series of square knots Surgeon: 1697 Additional Note: green linear tattoo placed parallel to incisions

8/16/2019

SO: pre neuter exam BAR in kennel eyes clear, no ocular or nasal d/c no congestion, coughing, sneezing seen during observation period heart ok no murmurs detected, lungs clear A: ok for neuter P: neuter

8/17/2019

SO Post op recheck. Skin -- incision site is clean and dry A post op sx site P continue to monitor post op