GIGI – 23361

DVM Intake Exam

Estimated age: 2
Microchip noted on Intake? yes

History : OS

Subjective: BAR

Observed Behavior – VERY FRACTIOUS – BITING AT NET COULD NOT PERFORM EXAM FOR HER OWN SAFETY AND THE STAFF SAFETY SO SEDATED PT TO REDUCE STRESS AND INJURY TO DO EXAM AND GIVE ALL TREATMENTS

Evidence of Cruelty seen – n

Evidence of Trauma seen – n

Sedated with Kitty Magic – 0.3 cc Ketamine, 0.1 cc dexmeditomidine, 0.15 cc Buprenorphine IM

Objective

T = –
P = 160 – under sedation
R = wnl
BCS = 6/9

EENT: Eyes clear, ears clean, no nasal or ocular discharge noted
Oral Exam: fractured canine 204 at the root level
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G: already spayed – tattoo and spay scar present
MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat – front limb polydactyl, claws on hind end bleeding due to resisting restraint and pressing feet against net and kennel
CNS: Mentation appropriate – no signs of neurological abnormalities
Rectal: externally normal

Assessment – healthy – fractured 204 Canine at level of the root

Prognosis: Excellent

Plan: Give intake treatments including 0.6 Onsior SQ due to fractured 204

Recommend – Recheck exam with referring vet at a later date to examine canine tooth (204)