HELENA – 31913

MANHATTAN CENTER

Helena 31913

Location: Manhattan

Intake Date: 6/21/18

Intake Type: Stray

Medical Behavior: Blue

Sex: Female

Age: 1 year

Original Location: 10452

DVM Intake Exam

Estimated age: Estimate 1 yr old based on dentition
Microchip noted on Intake? Scan neg- MC placed

History : Stray, no medical history available

Subjective: QAR
Observed Behavior- Came out of carrier and head butted handler’s hands. Did not like having foot wound touched, but allowed all other handling
Evidence of Cruelty seen – None
Evidence of Trauma seen – None

Objective
MM pink and moist, BCS 4/9

EENT: Ears clean. Moderate/heavy mucopurulent ocular and nasal discharge. Audible nasal congestion.
Oral Exam: Permanent dentition present, teeth clean
PLN: No enlargements noted
H/L: NSR, NMA, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G: Female intact
MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat. All nails long/overgrown. Digit 3 on the right front paw had the nail growing into the paw pad with a large scab around it. Multiple other nails were starting to grow into the paw pads and the digits had developed scabs. All nails trimmed.
Moderately prolonged skin tent.
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal: Normal externally

Assessment
1. URI- moderate, suspect viral with secondary bacterial infection
2. Ingrown nail/wound- RFL
3. Underweight
4. Dehydrated ~8%

Prognosis: Good

Plan:
1. Doxycycline 50 mg/ml susp: give 0.45 ml PO SID for 10 days
2. Nebulization BID for 7 days
3. Vitamin B12 0.25 ml SQ once
4. LRS 100 ml SQ for 4 days
5. Fortiflora 1 sachet in food SID for 7 days
6. Medical feeding- warmed wet food
7. Clean foot wound once a day for 5 days
8. Terramycin ophth soltn: apply to each eye BID for 7 days

SURGERY:
Temporary waiver due to URI

Hx: Admitted yesterday with URI, ingrown nails, underweight, dehydration. Started on doxy, nebs, vit B, SQF, Fortiflora, foot wound care, ophth ointment.

S: Alert, sitting still in kennel but comes to the front when I approach. Leans into petting, allows all handling.

O: BAR-H, BCS 3/9, MMs pink and moist, CRT <2 sec
EENT: Mild chemosis, mild serous ocular discharge. Clean ears and nose today. Mild tartar and moderate gingivitis.
PLNs: Not significantly enlarged.
H/L: NSR, NMA. Eupnic, quiet lung sounds, no coughing or sneezing.
Abd: Soft, no pain on palpation, no masses palpated
M/S/I: Right front foot has small scabs on the tips of the paw pads, no swelling or active bleeding. No lameness, amb x4. No skin lesions noted.
UG: Female
Neuro: Alert and appropriate, no sign neurological deficiencies

A:
1. URI – much improved from yesterday
2. Ingrown nails on RFL, trimmed yesterday – wounds healing well
3. Underweight – URI, good appetite

Short-term prognosis: Good

P:
1. Continue treatments as scheduled
2. Okay to move up to regular isolation

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