ROXIE – 20368

DVM Intake Exam

Estimated age: 1 year
Microchip noted on Intake? no
Microchip Number (If Applicable):

History : owner surrender due to grand-daughter’s allergies

Subjective: BAR-H

Observed Behavior – nervous but allows all handling without aggression

Evidence of Cruelty seen – no

Evidence of Trauma seen – no

Objective

T =
P = 180
R = eup
BCS 6/9

EENT: Eyes clear, ears clean, no nasal or ocular discharge noted
Oral Exam: mild gumline hyperemia, no oral lesions
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G: SF, green tattoo on abdomen; bladder large and somewhat firm
MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal: NP

Assessment
1 year old SF DSH
1. Healthy
2. Large/somewhat firm bladder r/o nervous and not using LB

Prognosis: Excellent

Plan:
1. All intake procedures already performed
2. Monitor for urinations
3. Make available for adoption

SURGERY: already spayed