SAUL – 21514

DVM Intake Exam

Estimated age: ~9-12 months
Microchip noted on Intake? No

History : Stray
Subjective: BARH
Observed Behavior – Attention seeking, very affectionate, allows all handling
Evidence of Cruelty seen – No
Evidence of Trauma seen – No

Objective
P = WNL
R = WNL
BCS 5/9

EENT: Eyes clear, ears clean, no nasal or ocular discharge noted
Oral Exam: Minimal wear, very mild staining, pink mm
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G: Male
MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat except for face – deep abrasions and inflammation above both eyes, wounds and hair loss at forehead, wounds to both ears (L>R), singed stiff edges of pinnae
CNS: Mentation appropriate – no signs of neurologic abnormalities

Assessment: Wounds to face, suspect burns

Prognosis: Good
Plan: Convenia 0.3ml SQ and simbadol 0.4ml SQ given. Wounds cleaned with nolvasan, dried and thin layer of SSD applied. Continue with simbadol 0.4ml SQ q24 x 3 days, novasan q24 x 3 days, SSD q12 x 3 days.

SURGERY:
Okay for surgery