GORDON – 35223

Vet Notes: 6:02 PM

DVM Intake Exam

Estimated age: Estimated 7-10 years based on dentition and overall appearance
Microchip noted on Intake? Scanned negative

History : Surrendered with 1 other cat.

Subjective: Alert, walked around on exam table

Observed Behavior – Allowed all handling, leaned into butt scratches and curled up on exam table while I was scratching his butt

Evidence of Cruelty seen – None

Evidence of Trauma seen – None

Objective
BAR-H, MMs pink and moist, BCS 4/9
EENT: Moderate discharge AU, shaking head. Eyes clear, no nasal or ocular discharge noted.
Oral Exam: Halitosis, moderate tartar, missing many maxillary teeth including canines. Right mandib canine is missing; left mandib canine is present but very loose and there is marked gingival recession.
PLN: No enlargements noted
H/L: NSR, NMA, Lungs clear, eupnic
ABD: Soft, non painful, no masses palpated, not distended
U/G: Male neutered
MSI: Polydactyl front feet. Ambulatory x 4, skin free of parasites, no masses noted, shedding heavily
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal: Normal externally

Assessment:
1. Dental disease
2. Suspected ear mites
3. Polydactyl

Prognosis: Good

Plan:
1. Clean ears q3 days x4 cleanings, Tresaderm AU BID x10 days
2. Recommend ASAP dental cleaning and rads with extractions

1088

A volunteer writes: Friendly and outgoing, Gordon LOVES attention. He’ll strut back and forth across the condo, catching your eye to make sure you’re appreciating him. He’ll reward you by pushing again your knuckles to get a really good rub.

CAME IN WITH

Amelia 35224