JEAN – 17912

DVM Intake Exam
Estimated age: 8 months
Microchip noted on Intake? neg
Microchip Number (If Applicable):

History :stray cat; finder reports that she had bloody diarrhea in the snow where he found here

Subjective: BAR, very affectionate and interactive, possibly in heat due to hyperaffection?

Evidence of Cruelty seen -n

Evidence of Trauma seen -abrasion on nasal planum

Objective
BCS 5/9

EENT: Eyes clear, AU-minimal waxy debris, mildly pruritic; ulceration/abrasion of nasal planum with mild serousanguinous drainage; no nasal discharge, sneezing or other URI signs
Oral Exam: mm pk, moist; CRT <2 sec; adult dentitia with no staining or tartar
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: soft, nonpainful, no palpable abnormalities; mild fecal staining in fur on tail
U/G: female intact
MSI: Ambulatory x 4, mild dandruff, no masses noted, healthy hair coat
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal:grossly normal

Assessment
1. Nasal abrasion-appears traumatic and not infectious
2. h/o bloody diarrhea-r/o parasites vs other

Prognosis:good

Plan:
-convenia 0.2 ml SQ
-fortiflora SID x 5 days
-monitor for diarrhea

SURGERY:
Okay for surgery