JENGA – 22520

DVM Intake Exam

Estimated age: 3yo
Microchip noted on Intake?
Microchip Number (If Applicable):

History : O passed away.

Subjective: BARH. Nervous and scared, ears down, scrunched posture, but well behaved during PE and med handling.

Observed Behavior –

Evidence of Cruelty seen – n

Evidence of Trauma seen – n

Objective

T =
P = 240
R = wnl
BCS 4/9

MM pink, slight delay in skin turgor
EENT: Eyes clear, ears mild ceruminous dc, no nasal or ocular discharge noted
Oral Exam: mild staining
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G: MI, 2 testicles
MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal: normal externally

Assessment
mild dehydration

Prognosis: good

Plan:
plan for neuter
Gabapentin (50mg/ml) 2mL PO once
LRS 100mL SQ

SURGERY:
Okay for surgery