BUBBA – A1120373

Brooklyn Center

Bubba A1120373 – 7 week old black/white kitten:

DVM Intake Exam

 

Estimated age: 7 weeks

Microchip noted on Intake?  no

 

History :  found in street, possible hit by car.

 

Subjective: QAR, mildly dehydrated

 

Observed Behavior – Quiet, possibly a little shocky on presentation. Did eat some canned food after inital examination,

 

Evidence of Cruelty seen – no

 

Evidence of Trauma seen – yes

 

 

Objective

 

T =                             P =      120                     R =           20                    BCS: 3-4/9

 

EENT:  Conjunctivitis OU, laceration/swelling OD (palpebral), thin bloody discharge from nostril (scant). No blood noted in ears

Oral Exam:  No obvious fractures, negative oral exam

 

PLN:  No enlargements noted

 

 

H/L:  NSR, NMA, CRT < 2,    Lungs clear, eupnic

 

 

ABD:  Non painful, no masses palpated

 

 

U/G:  female intact

 

 

MSI:  Ambulatory x 4, skin free of parasites, no masses noted, dirty coat

 

 

CNS:  mentation appropriate – no signs of neurologic abnormalities, seems alert and appropriate despite injury to head

 

Rectal:  not done

 

 

Assessment: stray, possible hit by car (glancing blow?), injuries to right eye as above, conjunctivitis OU

 

 

 

Plan:

25 ml LRS sq

Onsior: 0.06 ml sq

fvrcp vax

microchip placed

frontline spray

pyrantel/ponazuril PO

erythromycin ophthalmic OU bid x 10 days

monitor appetite/attitude

Prognosis: fair to good

 

SURGERY:

Temporary waiver due to   trauma/conjunctivitis as above

 

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