NIEBLA – 25201

DVM Intake Exam

Estimated age: 2yrs.
Microchip noted on Intake? scanned negative by LVT on intake.

History : stray brought in by good Samaritan; suspected to be pregnant and noted to have an eye injury that looks better.

Subjective / Observed Behavior – QAR; tries to flee. allows all handling.

Evidence of Cruelty seen – none
Evidence of Trauma seen – none

Objective
BCS 6/9
EENT: ears clean, no nasal or ocular discharge noted; multifocal pinpoint ulcerations OD with corneal thickening and increased opacity and synechia (suspect deep corneal ulcer that is resolving);
Oral Exam: dc 1/5; pd 1/5 ; mild to moderate gingivitis
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G: intact; multiple palpable fetuses; suspect mid to late-term pregnancy
MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal: grossly normal.

Assessment
pregnant, suspect mid to late-term.
dental calculus
periodontal disease
corneal ulceration — resolving.

Prognosis:
good.

Plan:
ok for sx.
erythromycin OS x 3 days. — first dose given at intake.
repeat fluorescent eye stain in 3 days.

SURGERY:
Okay for surgery