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
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
3. Likely ear mites
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
Temporary waiver due to URI
[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.
Recheck URI day 7. BAR in kennel.
EN -- eyes are clear. sneezing, slight audible congestion
nebulization q24h x 5 days
extend doxycycline 0.9ml PO q24h x 10 days
On treatment for moderate URI in iso
eating well. BAR in kennel
moderate nasal congestion
addition of little remedies 1 drop each nostril BID x3d
Hx: has had URI; FIV (+)
eent- oral pain; difficult to assess oral cavity
resolved URI but has oral pain most likely from dental disease (cannot assess oral cavity completely without sedation)
Stomatitis/gingivitis causing secondary oral pain
rec'd dental treatment and full oral exam
concerned about gingivitis and stomatitis
EENT- oral pain and gingivitis; limited oral exam due to pain
oral cavity inflammation
move out of ISO
monitor appetite closely
consider sedation and oral exam
needs dental rx
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
Additional Note: green linear tattoo placed parallel to incisions
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
ok for neuter
Post op recheck.
Skin -- incision site is clean and dry
post op sx site
continue to monitor post op
Fecal flotation under sibling # 70089 positive for coccidia eggs
Anesthesia Summary – Feline Neuter
Ketamine 100mg/mL injectable, 0.2 mL IM
Dexdomitor 0.5mg/mL injectable, 0.09 mL IM
Butorphanol 10mg/mL injectable, 0.09 mL, IM
Testicular block: lidocaine/sterile water: 0.2mL/0.2mL, administered pre-operatively.
No intubation or IV catheter
Perioperative pain medications:
Simbadol 1.8mg/mL injectable, 0.6 mL SQ, given pre/post-operatively.
Onsior 20mg/mL injectable, 0.5 mL, SQ, given post-operatively.
Antisedan 5 mg/mL injectable, 0.09 mL IM at 3:37 PM
Surgical monitor: 1578