APPLE – A1114766

Staten Island Center

A1114766 – Apple – 4 week black/white female – .8lb

DVM Intake Exam

Estimated age: approx 4 weeks

Microchip noted on Intake? scan negative

History : stray; diarrhea seen in carrier; eating canned food well

Subjective:

Observed Behavior – very vocal, tolerated exam

Evidence of Cruelty seen – no

Evidence of Trauma seen – no

Objective

BCS 5/9

EENT: Eyes clear, ears clean, no nasal discharge noted

Oral Exam: deciduous teeth

PLN: No enlargements noted

H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic

ABD: Non painful, no masses palpated

U/G: FI

MSI: standing on all 4 limbs but was reluctant to walk, falls to the left intermittently, skin free of parasites, no masses noted, healthy hair coat

CNS: mentation appropriate, severe head tilt to the left

Assessment

head tilt- R/O infectious vs trauma vs congenital condition vs toxin vs other

diarrhea- R/O infectious vs dietary vs other

Plan

parvocite snap test:

recommend transfer for furhter diagnostics and treatment

Prognosis: guarded

SURGERY:

Temporary waiver due to underage and neurologic disease

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