PANTERA – 25865

DVM Intake Exam

Estimated age: Reported 9 years old, exam is consistent with this
Microchip noted on Intake? Scanned POSITIVE on intake
Microchip Number (If Applicable):

History: Surrendered. “Pantera’s owner stated that Pantera has been sick for the past few weeks. She has been vomiting and has had diarrhea. The client stated that the only food Pantera has been able to hold down is Fancy Feast grilled chicken canned food. She stated that she took Pantera to the vet in January 2018 for the same problem and the doctor only gave her medication for the vomiting and for a “hard stomach.” The client stated that when Pantera gets anxious or stressed she will begin to chew on things and this may be the cause of her hard stomach. The owner stated that Pantera still seems to have good energy and eats every day, as long as its that one specific fancy feast flavor.”

Subjective: Alert, sits on exam table and allows all handling

Observed Behavior – Sits in one place and allows all handling

Evidence of Cruelty seen – None

Evidence of Trauma seen – None

Objective
BAR-H, MMs very pale, BCS 4/9
EENT: Some food or discharge smeared on muzzle. Eyes clear, ears clean, no nasal or ocular discharge noted
Oral Exam: Mild tartar.
PLN: No enlargements noted
H/L: NSR, NMA, Lungs clear, eupnic
ABD: Full of food, soft, non painful, no masses palpated
U/G: Female, no SS seen on ventral abd
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. 3-week hx of vomiting and diarrhea – client reports that pt eats inappropriate objects. R/O IBD vs. enteritis secondary to dietary indiscretion vs. other
2. Pale MMs – R/O anemia vs. other

Prognosis: Fair

Plan:
1. CBC/chem/T4
2. Monitor in medical

SURGERY:
Temporary waiver due to vomiting and diarrhea