MATZO – 35590

DVM Intake Exam

Estimated age: Estimated 7-10 years based on dentition and overall appearance
Microchip noted on Intake? Scanned neg

History : Stray, came in with 1 other cat who also has urinary tract disease

Subjective: Alert, looks around, sits on exam table and doesn’t walk around. Straining to urinate, bloody urine on his penis, pt yowls when I palpate his bladder.

Observed Behavior – Allows all handling, seems subdued

Evidence of Cruelty seen – None

Evidence of Trauma seen – None

Objective
BAR-H, MMs pink and moist, BCS 8/9
EENT: Eyes clear, ears clean, no nasal or ocular discharge noted
Oral Exam: Severe tartar and gingivitis, gingival hyperplasia on right mandib PMs/Ms
PLN: No enlargements noted
H/L: NSR, NMA, Lungs clear, eupnic
ABD: Soft, large, difficult to palpate. Pt yowls on bladder palpation.
U/G: Male neutered, bloody orange-red urine on the tip of his penis.
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:
1. Stranguria and hematuria – R/O FLUTD with partial urethral obstruction
2. Obese
3. Dental disease

Prognosis: Fair with treatment

Plan:
1. UA – collected urine free catch
2. CBC/chem
3. Sedate with butorphanol 0.2 ml, Dexdomitor 0.13 ml, ketamine 0.3 ml IM
4. Abd rads
5. IVC placement – run IV LRS at 17 ml/hr
6. Place urethral catheter