CASEY – 31966

Brooklyn Center

FELV+

Casey 31966- 5 weeks old, Male, Domestic Short Hair, White and Brown Tabby, Stray, 1 pound 1.92oz-

Medical:

23-Jun-2018
Progress Exam
Vet Notes: 1:50 PM

Vet check – monitor condition/appetite, severe conjunctivitis and FeLV+

S/O: BAR. ~5% dehydration. Eating well with minimal coaxing. BCS 3/9
EENT: Pink mm, teeth clean and erupting normally, no oral ulcers, moderate conjunctivitis OU, no nasal discharge observed, ears clean
HL: Normal thoracic auscultation, no sneezing observed
ABD: Soft, non tender
INTEG: Full coat
MS: Ambulatory x 4
UG: Male

A: Underage, FeLV, conjunctivitis/URI, underweight

P: Continue with current treatment and monitoring plan. Fair prognosis
VET 990844

22-Jun-2018
DVM Intake
Vet Notes: 2:42 PM

DVM Intake Exam

Estimated age: 4-6 weeks
Microchip noted on Intake? no
Microchip Number (If Applicable):

History: A client came in QACC with a kitten that has possible URI. The client stated that the kitten allowed to be picked up and was standing around meowing.

Subjective: Kitten is QARH

Observed Behavior – kitten cannot see due to severe chemosis OU, but orients towards people and allows all handling

Evidence of Cruelty seen – no

Evidence of Trauma seen – no

Objective

T = NA
P = wnl
R = wnl
BCS 3/9

EENT: Eyes – severe chemosis with mucopurulent ocular discharge OU, ears clean, no nasal discharge, audible congestion or sneezing noted
Oral Exam: healthy deciduous dentition
PLN: submandibular LNs slightly enlarged
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G: male, wnl
MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal: not performed

Assessment: Underage/underweight, Severe conjunctivitis, FeLV+

Prognosis:
Fair-Good

Plan: Keeping in medical because kitten is not eating. Recommend foster or NH placement. Flushed OU with eye wash and applied erythromycin – cont BID x 10d. Start Doxycycline 50mg/ml – 0.1mls PO q24h x 10d; gave first dose around 2:30pm on 6/22/18. Neblulize BID x 3d.

SURGERY:
Temporary waiver due to underage/underweight and URI

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