2/3/2018

[DVM Intake] DVM Intake Exam Estimated age: 5 Microchip noted on Intake? n Microchip Number (If Applicable): n History : OS Subjective: BAR Observed Behavior - Allowed easily for a full PE Evidence of Cruelty seen - N Evidence of Trauma seen - N Objective T = - P = 80 R = WNL BCS - 5/9 EENT: Eyes clear - mild otitis externa in right ear and debris, no nasal or ocular discharge noted Oral Exam: Teeth in good condition PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: Intact male - two descended testicles MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat CNS: Mentation appropriate - no signs of neurological abnormalities Rectal: UR Assessment: Healthy Mild pruritis in right ere - cleaned ear with otic solution and applied otibiotic ointment . Prognosis: Excellent Plan: Neuter SURGERY: Okay for surgery

2/6/2018

Pre-op exam S: Alert, relaxed, soft body. Allows all handling. O: BAR-H, BCS 4/9, MMs pink and moist, CRT <2 sec EENT: No discharge OU, AU, nose. Mild tartar. All four canine teeth are fractured and the right maxillary canine is fractured at an oblique angle down to the neck of the tooth; the root is clearly exposed. Mild tartar. PLNs: Not significantly enlarged. H/L: NSR, NMA. Eupnic, quiet lung sounds. Abd: Soft, no pain on palpation, no masses palpated M/S/I: Right 5th digit is fractured and the distal 1-2 phalanges are missing, so there is no nail and the skin flops to the side. No swelling, skin lesions or pain. Amb x4. Ventral neck and chest are slightly erythematous. UG: Male intact, testicles soft and symmetrical. Neuro: Alert and appropriate, no sign neurological deficiencies A: 1. Fractured teeth with root exposure - these teeth may be infected and painful for Jay Jay, or they may get infected in the future. 2. Right 5th digit - old injury, no treatment needed 3. Dermatitis on ventral chest - R/O allergies vs. physical abrasions vs. other Short-term prognosis: Good P: Neuter today 1088

2/6/2018

Surgery report Was this dog a cryptorchid? No - normal adult male Pre scrotal Incision Spermatic Cord Ligation with: 0 PDS in modified Miller's knots (double-ligated both cords) Sub Q closure: 0 PDS in simple continuous pattern Skin closure? 0 PDS in intradermal pattern Linear green tattoo near incision site to denote neuter status 1088

2/8/2018

[DVM Intake] DVM Intake Exam Estimated age: 5 Microchip noted on Intake? y Microchip Number (If Applicable): 981020019273596 History : Owner reported that Jay Jay was coughing, sneezing and had nasal and mucoid dis-c since returning from SX at ACC. Subjective: BAR Observed Behavior - Energetic, observed sneezing a few times while in the exam room Evidence of Cruelty seen - n Evidence of Trauma seen - n Objective T = n P = 100 R = WNL BCS = 5/9 EENT: Eyes clear, ears clean, no nasal or ocular discharge noted, Oral Exam: MMB tachy PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: Incision site looks healthy MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat CNS: Mentation appropriate - no signs of neurologic abnormalities Rectal: Assessment: CIRDC - Based on the history and sneezing in the exam room Prognosis: Good Plan: Doxycycline 300 mg SID for 14 days Cerenia 60mg SID for 3 days

2/12/2018

DVM Intake Exam Estimated age: 5 years per our previous records Microchip noted on Intake? Scanned POSITIVE on intake Microchip Number (If Applicable): 981020019273596 History : Pt was here earlier this month; pt was neutered on 2/6/18. Pt came back for a re-exam on 2/8 due to c/s - was diagnosed with CIRDC and started on doxycycline. Being surrendered today. Subjective: Alert, relaxed Observed Behavior - Calm, allows all handling Evidence of Cruelty seen - None Evidence of Trauma seen - None Objective BAR-H, MMs pink, BCS 5/9 EENT: Mild serous nasal discharge. Eyes clear, ears clean, no ocular discharge noted. Oral Exam: Fractured canines as previously described. Mild tartar. PLN: No enlargements noted H/L: NSR, NMA, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: Male neutered. Scrotum is soft and empty. Incision site is clean and dry, with no swelling, discharge or erythema. 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: CIRDC Prognosis: Good Plan: Move to isolation, continue doxycycline. 1088

2/15/2018

S/O -BAR, appears friendly and energetic at front of kennel -mild serous nasal discharge -eupnic A 1. CIRDC, resolving P -recheck in 2 days

2/16/2018

S/O -BAR, appears friendly and energetic at front of kennel -mild serous nasal discharge- mainly L nare -eupneic A 1. CIRDC, resolving P -recheck in 2 days

Upon intake Jay Jay allowed handling. he had a relaxed body, wagging tail and was receptive to head and body touches. he allowed being collared and posed nicely for a picture. He allowed being placed in a kennel and remained with a very relaxed body.