CLEM – A1105495

BROOKLYN CENTER

CLEM – A1105495

NEUTERED MALE, ORG TABBY / WHITE, DOMESTIC MH,1 yr
OWNER SUR – EVALUATE, NO HOLD Reason ALLERGIES
Intake condition EXAM REQ Intake Date 03/16/2017, From NY 11203, DueOut Date 03/16/2017, I came in with Group/Litter #K17-091082.

Clem  is a one year old orange tabby male domestic shorthair. He was surrendered due to allergies of a family member. He was given to owner by a friend and was with his owner for about six months.

 

Clem has lived with one adult in his previous home and another male cat. Clem is described as shy around strangers and stays hidden in the home. He will take several days to warm up to new people. Clem spent time with a twelve year old child and was described as gentle with the child. Clem has not bitten in his previous home.

 

Clem is litterbox trained and uses a hooded litterbox and clay litter. Clem does not like to be held and will flee. Clem eats dry and wet food Purina One and is fed twice a day. Clem has been kept only indoors. Clem scratches at owner’s rubber mats on the floors.

 

Upon intake Clem was shy and moved his head towards the back of the cardboard carrier. Clem was receptive to handling, counselor was able to collar, scan (negative) and photograph.

 

MEDICAL:

DVM Intake Exam Findings

scan negative

History   family member allergic

Subjective    owner surrender 

Observed Behavior –  timid

Evidence of Cruelty seen –  none

Evidence of Trauma seen –  none

 

Objective    qarh

  P =   wnl     R =    wnl    BCS 5/9

 

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

Oral Exam:   bleeding gums, halitosis

PLN:  No enlargements noted

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

ABD:  Non painful, no masses palpated

U/G:   scrotal testes

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 gingivitis

Medical Behavior Status green

Medical Status 2NC

Asilomar Status TREATMANAG

Fast Track NO TOO OLD

 

Plan

CLEAR FOR SURGERY

START CLINDAMYCIN 25MG PO SID X 10 DAYS

Weight 9.0

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