JENSON aka JENI – 21551

DVM Intake Exam

Estimated age: 2yo
Microchip noted on Intake? neg
Microchip Number (If Applicable):

History : picked up from a hoarding case

Subjective: Q-BAR. Friendly, purring, and allows for all med handling, no signs of aggression.

Observed Behavior –

Evidence of Cruelty seen – n

Evidence of Trauma seen – n

Objective

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

MM pink and moist, normal skin turgor
EENT: OU clear. Ears have mild amount of black/brown debris. Lateral base of right ear has wound of unknown origin, abscess. Abscess was squeezed until no more purulent discharge came out, followed by bloody discharge. Pet was well behave, comfortable, purring. No nasal or ocular discharge. Abrasions on dorsal surface of nose.
Oral Exam: No ulcers/lesions. Missing lower canines
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2 seconds. Lungs clear and eupnic
ABD: Non painful, no masses palpated. Moderately sized bladder, nonpainful
U/G: MI, 1 testicle palpated, round and smooth
MSI: Ambulatory x 4, skin free of parasites, no masses noted, fair dirty haircoat. Small pinpoint scabbed wound on top of head.
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal: normal externally

Assessment:
abscess on right ear — r/o trauma (puncture vs other)
dental disease
cryptorchid

Prognosis: good

Plan:
plan for cryptorchid neuter
start clavamox give 0.8mL PO x 7 days
vet check abscess 3/1/18. If no improvement, consider sedated wound explore and flush

SURGERY:
ok for surgery

CAME IN WITH