MISTY – A1125961

Manhattan Center

Misty A1125961, 13 weeks, Gray DMH F

Initial Exam (9/19/17)

DVM Intake Exam

Estimated age: 3 m

Microchip noted on Intake?  n

History :  stray

Subjective:  draining tract in area of left  anal gland. Large flucuant swelling in right inguinal area (hernia vs abscess?)

Observed Behavior – BAR

Evidence of Cruelty seen – n

Evidence of Trauma seen – n

Objective

  t-103.3  P =     200                      R =     wnl                          BCS3/9

EENT:  Eyes clear, ears clean, no nasal discharge noted

Oral Exam:  decid teeth

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

CNS:  mentation appropriate – no signs of neurologic abnormalities

Assessment: open diagnosis: rule out retroviral dz

Plan: clavamox 0.2ml bid x 14 d, 1st dose given

Prognosis: guarded

SURGERY: underweight

Re-Exam (9/20/17)

Hx: Came in yesterday with a draining tract in the region of the left anal gland, and (separately) a large fluctuant swelling in the right inguinal region – R/O hernia vs. abscess. Temp 103.3.

S: Eating, purring, allows all handling

O: BAR-H, BCS 3/9, MMs pink

EENT: Mild mucoid ocular discharge. Mild nasal crusting. Clean ears. Food-covered deciduous teeth.

PLNs: Not significantly enlarged.

H/L: NSR, NMA. Eupnic, quiet lung sounds.

Abd: Large fluctuant mass in the right inguinal region. No pain on palpation, no masses palpated.

M/S/I: Amb x4. No skin lesions noted.

UG: Female

Neuro: Alert and appropriate, no sign neurological deficiencies

Rectal: Small left anal gland fistulated abscess, smeared debris around anus.

Cleaned anus – no current discharge from abscess.

A:

1. Anal gland abscess

2. Inguinal hernia

3. URI

Short-term prognosis: Fair

P:

1. Continue Clavamox, daily anus cleaning

2. Recommend surgical correction of inguinal hernia

Enrichment

Comes forward and meows, soliciting attention. Head-butts lightly when pet and leans in, purring. Remains soft throughout interaction and allows all handling. Will continue to meow after interaction ends.

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