DONNA – A1115728

Brooklyn Center

Donna A1115728, 4-5 Weeks Old, Black and White DSH, Female, 1.2 lbs

Medical::

DVM Intake Exam

Estimated age: 4-5 wks

Microchip noted on Intake?  no

History: Found as stray.

Subjective: Kitten is BAR.

Observed Behavior – readily approaches veterinarians, purring. no “warm up” time needed. little restraint required for exam. allows all body parts to be touched without signs of discomfort. curious, willing to explore environment.

Evidence of Cruelty seen – no

Evidence of Trauma seen – no

Objective

T =           NA                  P =     wnl                      R =         wnl                      BCS 4/9

EENT:  OU – mild-moderate blepaharospasm and chemosis with mucopurulent discharge, mild debris AU, bilateral mucopurulent nasal discharge

Oral Exam:  healthy deciduous dentition

PLN:  No enlargements noted

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

ABD:  Non painful, no masses palpated

U/G: 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, URI (with conjunctivitis)

Plan: Cleaned eyes and applied erythromycin OU – continue BID x 10d. Start doxycycline liq. – 0.1 mls PO q24h x 10d. Gave first dose. Recheck day 7 and 10. Recommend foster or rescue placement asap.  Move to ISO. Continue to monitor while at BACC.

Prognosis: Good

SURGERY:  Temporary waiver due to underage/underweight and URI

 

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