1/6/2018

DVM Intake Exam Estimated age: mature adult, 3-5 yr Microchip noted on Intake? scan negative Microchip Number (If Applicable): placed on intake # 981020019268221 History: abandoned/stray Subjective: BAR, mildly dehydrated Observed Behavior - calm, allowed PE, sensitive to injury but not aggressive Evidence of Cruelty seen - no Evidence of Trauma seen - yes, left rear paw Objective HR/RR wnl BCS 5/9 EENT: Eyes clear, ears clean, no nasal or ocular discharge noted Oral Exam: nsf PLN: No enlargements noted H/L: nsf, NSR, NMA, CRT < 2; Lungs clear, eupnic ABD: mildly distended gaseous on palp, non-painful, no masses palp. U/G: intact male, nsf MSI: Ambulatory x 4, moderated swelling/painful left rear paw with mild serosanguineous discharge from small wound on bottom also has scabbing and alopecia on dorsal aspect of the same paw; alopecia on medial right elbow; heavy flea dirt; mildly dirty coat CNS: Mentation appropriate - no signs of neurologic abnormalities Rectal: externally normal Assessment: - flea dirt - mildly dehydrated - left rear paw wound/infection + pain - alopecia Prognosis: good Plan: clean and monitor wound + 1 ml Clavamox (62.5 mg/ml) PO BID x 10 days + 0.4 ml Onsior SQ SID x 3 days + rec' Wood's lamp test alopecia + RW culture Surgery: Ok for neuter surgery

1/8/2018

Hx: small wound and patch of alopecia noted on LH paw on intake; started on clavamox S/O -BAR, interactive and friendly; mewing constantly at front of cage -good appetite -2 episodes of liquid brown diarrhea within 30 minutes this morning -mm pk, moist -no nasal discharge or sneezing -eupnic -soft abdomen -LH: small wound with patch of alopecia on dorsal aspect of paw; no significant swelling or discharge A 1. Wound, healing well 2. Diarrhea-r/o secondary to clavamox vs stress vs other P -d/c clavamox, give convenia 0.4 ml SQ -fortiflora SID x 7 days -monitor for persistent diarrhea, if noted, then add metronidazole and consider fecal exam

1/10/2018

S/O -BAR, appears docile and friendly -good appetite -large slightly soft stool in box -no nasal discharge or sneezing -OU: open and clear -wound on LH paw appears to be resolving with no discharge or swelling noted A 1. Diarrhea-r/o secondary to clavamox vs other 2. Wound, healing well P -CWCT

1/11/2018

Recheck wound on LH, also had episode of diarrhea on 1/8 so clavamox was d/c and he was given convenia S/O -QAR, less interactive than usual -good appetite -episode of diarrhea reported this morning but cage was cleaned prior to exam -mild sniffling, reportedly sneezed twice yesterday -OU: mild blepharospasm -eupnic -LH: small wound with patch of alopecia and erythema on LH; no significant swelling or discharge; appears fully weight bearing A 1. Wound, healing well 2. URI 3. Diarrhea, r/o stress vs secondary to URI vs other P -move to isolation -cerenia 0.4 ml SQ SId x 2 days -monitor for persistent diarrhea -due to high suspicion of a viral URI, we do not recommend treating with antibiotics unless mucoid nasal discharge develops or course is prolonged or severe

1/14/2018

Was placed on Clavamox for a wound on LH; noted to have diarrhea so clavamox was d/c and he was given a convenia injection and started on fortiflora S/O -QAR, docile and friendly but less interactive than usual -good appetite -no diarrhea in cage or reported -soft sneezing, serous nasal discharge -eupnic -soft abdomen A 1. Diarrhea-r/o secondary to clavamox vs secondary to URI vs sress vs chronic GI P -extend fortiflora -cerenia 0.4 ml SQ SID x 2 days -nebulize SID x 3 days

1/17/2018

Recheck URI, day 7 in isolation; suspected viral URI initially so no antibiotics added; has had diarrhea intermittently and started on metronidazole yesterday S/O -BAR, friendly, allows handling -great appetite -large soft but formed stool in box -no obvious nasal discharge but significant nasopharyngeal congestion -OU: mild blepharospasm -eupnic -wound on LH paw appears to be resolving A 1. Wound, resolving 2. URI 3. Diarrhea P -initially suspected viral URI, appears to be improving but slowly; will add doxycycline and monitor for improvement or worsening -doxycycline 0.9 ml PO SID x 10 days

1/20/2018

Recheck URI, day 10 in iso: S/O: BARH - e/d well - mild serous nasal discharge + sneeze observed A: mild resolving URI P: cwct and recheck

1/21/2018

Persistent diarrhea, started on fortiflora; episode of diarrhea reported last night S/O -QAR, more interactive than was on previous exam -moderate appetite, no diarrhea in cage or reported this morning -no nasal discharge or sneezing -OU: mild blepharospasm -appears eupnic -soft abdomen A 1. URI-possibly resolved 2. Diarrhea-r/o stress vs diet change vs doxycycline vs parasites vs chronic GI disease (IBD vs other) P -metronidazole 1 ml PO BID x 7 days -if diarrhea persists or reoccurs, then recommend fecal float +/- diet trial with hypoallergenic diet

1/21/2018

re wt from 9.0 to 10.5