GUS GUS – 12730

DVM Intake Exam
Estimated age: 4 weeks
Microchip noted on Intake? no
History : stray, with diarrhea
Subjective: BAR, hydrated, eating well in kennel on its own.
Observed Behavior -friendly, allows exam and treatment with minimal restraint.
Evidence of Cruelty seen -no
Evidence of Trauma seen -no
Objective
P =120
R =wnl
BCS: 4/9
EENT: Conjunctivitis and crusty ocular discharge OU, ears clean, no nasal discharge noted
Oral Exam: negative oral exam
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G: male intact
MSI: Ambulatory x 4, skin free of parasites, no masses noted, dirty hair coat, diarrhea caked on perineal area.
CNS: Mentation appropriate – no signs of neurologic abnormalities
Assessment:
Diarrhea
conjunctivitis
Prognosis: good with treatment
Plan:
clean eyes, start on erythromycin BID
parvo snap test negative.
quick bath to clean up diarrhea.
SURGERY:
Temporary waiver due to age/wgt/conjunctivitis