11/15/2017

[DVM Intake] DVM Intake Exam Estimated age: Microchip noted on Intake? History : o surrender Subjective: Observed Behavior -calm, allows exam Evidence of Cruelty seen -n Evidence of Trauma seen -n Objective T = P =200 R =wnl BCS 5/9 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 U/G: no ss seen MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat CNS: Mentation appropriate - no signs of neurologic abnormalities Assessment:healthy Prognosis:excellent Plan:ohe SURGERY: Okay for surgery

11/17/2017

Presurgical exam and Sx notes: BARH BCS 6/9 - no c/s v/d observed/reported EENT: clean, clear, nsf Oral Exam: nsf PLN: No enlargements noted H/L: NSR, NMA; Lungs clear, eupneic; nsf ABD: soft abdomen, no masses palpated U/G: intact female MSI: skin free of parasites, no masses noted, clean coat CNS: mentation appropriate – no signs of neurologic abnormalities Rectal: externally normal A: ok for spay surgery Sx notes: mild hydrometra/distended uterus, otherwise routine OVH: Ventral midline incision approach; each ovarian pedicle was auto-ligated (w/pedicle tie) and excised distal to ligature; uterine body was double ligated with a modified-Miller's knot and a simple encircling ligature using 3-0 Monocryl and excised distal to ligatures; body wall closed with cruciate pattern using 3-0 Monocryl; subcutaneous/intradermal layers closed with continuous pattern using 3-0 Monocryl; green-ink tattoo placed lateral to spay incision; surgical glue applied to skin incision and over tattoo site to assist with closure

11/25/2017

[DVM Intake] DVM Intake Exam Estimated age: yo Microchip noted on Intake? y History : RTS, not eating at home, too shy Subjective: shy, but sweet Observed Behavior - Evidence of Cruelty seen - Evidence of Trauma seen - Objective Eating dry treats in carrier, did not like wet food T = P = 150 R = 20 BCS 5/9 EENT: Eyes clear, ears clean, no nasal or ocular discharge noted Oral Exam: PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: spay CDI MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat CNS: Mentation appropriate - no signs of neurologic abnormalities Assessment apparently healthy Prognosis: excellent Plan: offer choice of wet and dry SURGERY: NA

12/3/2017

S/O -QAR -mild appetite -sneezing, serous nasal discharge -OU: open and clear -eupnic A URI P move to isolation doxycycline 0.8 ml PO SID x 10 days

11/17/2017

Anesthesia Report: Pre-medication: 0.07 mL dexdomitor, 0.04 mL butorphanol, 0.35 mL ketamine. 0.5 mL Simbadol and 0.35 mL Robenacoxib given SQ during prep for pain management. Antisedan given after sx 0.03 ml IM. Start 0.5 cc simbadol 1.8 mg/ml sid x 3 days and 0.35 cc Robenacoxib 20 mg/ml sid x 3 days as pain management.