GRANDMA – 32455

DVM Intake Exam

Estimated age: ~4-6 years
Microchip noted on Intake? negative
History : o/s
Subjective: BARH
Observed Behavior – very sweet but a little slow to wam. Easily handleable. Did well for all medical handling and procedures.
Evidence of Cruelty seen – no
Evidence of Trauma seen – no

Objective
P = wnl
R = eupneic
BCS 6/9
EENT: Eyes clear, ears clean, no nasal discharge noted
Oral Exam: adult dentition with mild dental disease, no oral lesions noted
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic
ABD: Non painful, no masses palpated
U/G: FS (Spay scar noted on ventrum), no MGTs, no vulvar d/c
MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat
CNS: mentation appropriate – no signs of neurologic abnormalities

Assessment:
Mild dental disease
Overweight

Plan: Continue to monitor while at BACC
Rec weight loss
Rec dental in the future

Prognosis: Good

SURGERY: spayed