CENIZA – 27295

DVM Intake Exam
Estimated age:2 years
Microchip noted on Intake? neg
Microchip Number (If Applicable):

History :   owner surrender after cat fell 4 stories

Subjective:BAR

Observed Behavior -docile but painful, vocalizes when picked up

Evidence of Cruelty seen -n

Evidence of Trauma seen -dried blood, abrasion along nasal planum, lip; LH lameness

Objective
BCS 9/9

EENT: Eyes clear, AU-dark granular debris, pruritic; small amnt of dried bloody nasal discharge but no active discharge
Oral Exam:mm pk, tacky; mild tartar/staining; no obvious oral trauma, symphysis stable
PLN: No enlargements noted
H/L: mild tachypnea with normal effort, decreased lung sounds dorsally; no murmurs/arrhythmias
ABD: soft, nonpainful
U/G: female spayed, long spay scar noted on abdomen
MSI:
-LH: weight bearing lameness, decreased hip extension with pain and crepitus
-abrasion along nasal planum
-abrasion along caudal abdomen
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal:grossly normal

Assessment
1. High rise trauma
2. LH lameness
3. Suspect pneumothorax
4. Obesity
5. Ear mites

Prognosis:good

Plan:
-ivermectin 0.15 ml SQ, repeat dose in 2 weeks
-sedated with 0.2 ml ketamine/0.2 ml dexdomitor/0.2 ml torb IM for radiographs
-simbadol 0.6 ml SQ SID x 5 days, first dose given
-onsior 0.5 ml SQ SID x 3 days, first dose given

SURGERY:temp waiver due to trauma