COTTAGE – 33655

DVM Intake Exam

Estimated age:5w
Microchip noted on Intake?no
Microchip Number (If Applicable):no

History :stray

Subjective:bar

Observed Behavior -eating a small amount, amenable to all handling

Evidence of Cruelty seen -no

Evidence of Trauma seen -no

Objective

T =
P = 170
R = wnl
BCS 2/5

EENT: nasal and ocular d/c, will need enucleation os, od conjunctivitis
Oral Exam:deciduous 5w
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G: fi
MSI: Ambulatory x 4, skin free of parasites, no masses noted, dusty haircoat
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal:ne

Assessment: 5w fi dsh
1) conjunctivtis ou OS>OD – fhv vs bacterial vs other viral
2) uri – r/o viral vs bacteria
3) underweight

Prognosis: excellent w/ enucleation os

Plan:
1) erythromycin ou bid x 7 days
2) doxycycline 0.06 cc
3) 15 cc sq lrs sq sid x 7d
4) nebulize saline 15 min bid x 7 days