GIUSEPPE – 25336

DVM Intake Exam

Estimated age: 3 months
Microchip noted on Intake? no
Microchip Number (If Applicable):

History : stray

Subjective:

Observed Behavior – purring, friendly

Evidence of Cruelty seen – no

Evidence of Trauma seen – no

Objective

T = 98.5F
P = 160bpm
R = wnl
BCS 5/9

CRT: <2s. Gums: pink, moist
S: QAR, normal hydration
Eyes: Third eyelids raised OU, no discharge
Ears: Unremarkable AU.
Nasal Cavity: No nasal discharge.
Oral Cavity: deciduous dentition.
PLN: WNL
Heart: No murmurs or arrhythmias. Pulses adequate and synchronous.
Lungs: Eupneic, lungs clear. No crackles or wheezes bilaterally.
Abd: Soft, non-painful. No palpable masses. No organomegaly appreciated.
U/G: intact male with two descended testicles. No discharge.
Musculoskeletal: Ambulatory x 4 with no appreciable lameness. Mild to moderate generalized ataxia noted
Integument: Otherwise unremarkable haircoat.
Neuro: QAR/dull. CP WNL x4. Menace response and palpebral reflex WNL OU.
Rectal: Not performed. Externally normal.

Assessment
1) Dull mentation, ataxia- given patient’s age and being an outdoor cat (stray) top differentials would be infectious (toxoplasmosis vs FIV/FelV vs panleukopenia vs FIP) vs trauma vs congenital structural disease. Metabolic causes (electrolyte disturbance, hypoglycemia, liver/renal disease) is possible, but considered less likely. Less likely differentials include neoplasia, inflammatory meningitis.

Prognosis: fair to guarded

Plan:
Fluorescin stain- negative OU
CBC/Chem performed- unremarkable (Hct 27, though kittens normally have a lower hematocrit than adults)
Unable to perform parvo test as no feces

Administered 50mls LRS SQ once
Transferred to medical

Recheck tomorrow- perform parvo test? Consider toxo PCR if no improvement

SURGERY:
Temporary waiver due to medical