ALLIE – 21817

DVM Intake Exam

Estimated age: 7 based on dentition
Microchip noted on Intake? yes

History :     O surrender, O can no longer care for p.    O said p is shy.

Subjective: BARH. Nervous and scared, hissed a few times, ears down, tense and scrunched posture. Ok during PE and med handling, approached slowly.

Observed Behavior –

Evidence of Cruelty seen – n

Evidence of Trauma seen – n

Objective

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

EENT: Eyes clear, no nasal or ocular discharge noted. moderate amount of black debris AU, pinnal pedal reflex
Oral Exam: missing all canines. moderate dental disease
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G: FI, no vulvar discharge.
MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal: normal externally

Assessment:
ear mites
otherwise apparently healthy

Prognosis: good

Plan:
plan for OHE
applied Milbemite Otic AU
ctm at macc until transfer/adoption

SURGERY:
Okay for surgery