CONDADO – 24653

DVM Intake Exam

Estimated age:2 y
Microchip noted on Intake? none
Microchip Number (If Applicable):

History : stray cat, approaches people easily

Subjective: approaches people readily and seeks contact/touch. allows all handling

Observed Behavior –

Evidence of Cruelty seen -none

Evidence of Trauma seen – none

Objective

T =
P =180
R =20
BCS 5/9

EENT: Eyes clear, ears clean, crusty mucopurlent with a bloody tinge nasal discharge
Oral Exam: clean teeth mild ginigivitis
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated; kidneys easily palpated
U/G: intact male
MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal: clean on external evaluation

Assessment: Moderate URI with secondary bacterial infection

Prognosis: good

Plan: 1) gave 0.25 mL vitamin B12, repeat in 1 week
2) doxycyline 0.8 mL PO SID x 14 days
3) fortiflora with food
4) move to isolation
5) recheck with vet in 48 hours to reassess
6) when healthy schedule neuter

SURGERY:
Temporary waiver due to URI signs