GRINT – 18328

14/01/2018

[DVM Intake] DVM Intake Exam Estimated age: 2yrs Microchip noted on Intake? N Microchip Number (If Applicable): History: ACO impound- owner died Subjective: QAR Observed Behavior – compliant for exam Evidence of Cruelty seen – N Evidence of Trauma seen – Maybe- ddx viral ocular dz OD Objective T = DNP P = WNL R = WNL BCS 4/9 EENT: OS clear, OD mucopurulent discharge and suspected ruptured globe- pink tissue covers visible cornea, smaller than OS, mild ceruminous debris AU, no nasal or ocular discharge noted Oral Exam: Grade 1-2/4 tartar w/ mild gingivitis present over maxillary carnassials PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, lungs clear, eupnic ABD: Non painful, no masses palpated U/G: Suspected intact female- no visible spay scar or tattoo MSI: Underweight, ambulatory x 4, skin free of parasites, no masses noted, dirty / urine stained haircoat CNS: Mentation appropriate – no signs of neurologic abnormalities Rectal: Externally WNL Assessment: 1. Suspected ruptured globe OD- ddx viral vs. trauma vs. other 2. Underweight 3. Dental dz 4. FeLV positive Prognosis: Fair to good w/ enucleation Plan: Rec enucleation at time of spay. Rec dental cleaning in future. FeLV positive. SURGERY: Okay for surgery.

Cat is friendly and allows handling

ENRICHMENT NOTES:: 1/16/18 Curled up towards back, tense posture, eye dilated, hiding behind leg of kuranda bed. Lay in place when door opened, allowed all pets, no response at all. 1/17/18 Crouched towards back, tense, curled up tightly, eye dilated, hiding behind leg of kuranda bed. Flinched slightly when door opened, then lay in place. Tolerated all pets, absolutely no response.