TITANIO – 21809

DVM Intake Exam

Estimated age:
Microchip noted on Intake? 2yo
Microchip Number (If Applicable):

History : stray. Finder said p is walking abnormally.

Subjective: BARH. Nervous, very tense and scrunched up. Unable to assess gait. Well behaved during PE and med handling.

Observed Behavior –

Evidence of Cruelty seen – n

Evidence of Trauma seen – n

Objective

T =
P = wnl
R = wnl
BCS 4/9

EENT: Eyes clear, ears clean, no nasal or ocular discharge noted
Oral Exam: nsf
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: tense but non painful, no masses palpated
U/G: MI
MSI: Motor x 4, skin free of parasites, no masses noted, healthy hair coat. No overt signs of pain on palpation and flexion/extension of both HLs. Possible discomfort with left hip, but p was very tense.
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal: normal externally

Assessment:
intact
apparently healthy

Prognosis: good

Plan:
plan for neuter
ctm for any signs of lameness

SURGERY:
Okay for surgery