BUTTER BALL – A1112892
Safe - 6-2-2017 Staten Island
SAFE 6/2/17 Shy gal BUTTER BALL @ SIACC
Staten Island Center
Butter Ball A1112892– 1 year old, Spayed Female, Domestic Short Hair, Calico, 6.8 pounds
Medical:
DVM Intake Exam
Estimated age:
Microchip noted on Intake? scan negative
History : seized
Subjective:
Observed Behavior – friendly
Evidence of Cruelty seen – no
Evidence of Trauma seen – no
Objective
BCS 5/9
EENT: OD- conjunctival hyperemia and mild green mucoid discharge, OS- mild brownish discharge; AU- dry brown debris, no nasal discharge noted
Oral Exam: clean adult teeth
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic
ABD: Non painful, no masses palpated
U/G: Fi, no spay scar seen
MSI: Ambulatory x 4, skin free of parasites, no masses noted, large amount of flea dirt
CNS: mentation appropriate – no signs of neurologic abnormalities
Assessment
fleas
supsect ear mites
conjunctivitis
Plan
Apply erythromycin OU BID x 7 days
Prognosis: good
SURGERY:
Temporary waiver due to conjunctivitis
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