PERSIA – 16313

[LVT Intake Exam] Microchip Scan: negative Evidence of Cruelty: no Observed Behavior: relaxed, allowed handling Sex: female spayed Estimated Age:~6-8 years Subjective: describe how he animal is presenting and any known history Eyes: mild ocular d/c Ears: mild waxy Oral Exam: teeth- missing incisor teeth,moderate stained and tartar, gingivitis, nsf Heart: moderate loud heart beat, possible grade-3 heart murmur, or may be due to dehydration, vet is requested check. Lungs: wnl Abdomen: small cutaneous mass seen in ventral abdomen, Musculoskeletal: bcs- 3/9,emacited, dehydrated, underweight, skin coat-dry Mentation: QAR, no abnormal neuro sign. others- eating food but drinking lot of water. Preliminary Assessment: dehydration emaciation underweight gingivitis cutaneous mass in ventral abdomen Plan: needs DVM exam

[DVM Intake] DVM Intake Exam Estimated age: 8 years Microchip noted on Intake? n History : stray Subjective: 10 % dehydrated, scruffy hair coat/unkept Observed Behavior – allowed all handling Evidence of Cruelty seen – n Evidence of Trauma seen – n Objective T = P = 188 R = 24 BCS 3/9 EENT: Eyes clear, ears clean, no nasal or ocular discharge noted Oral Exam: pddz3/4, cracked canine upper right PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: female,spay scar noted MSI: Ambulatory x 4, skin flea dirt, no masses noted, dull hair coat CNS: Mentation appropriate – no signs of neurologic abnormalities Assessment – R/O causes for dehydration (CRF vs DM vs Hyperthyroid) Prognosis: gaurded Plan: CBC/CHEM/T4 NaCl 100 ml Sq

[Progress Exam Template] S: P eating food and drinking Loose diarrhea in litter box QAR O: EENT: Mild mucoid ocular discharge Oral Exam: Mild tartar, fractured upper right k9 tooth H/L: No m/a Abd: SNP MSI: Amb x 4, BCS 1.5/5 Mentation: QAR A: Azotemia- r/o CKD vs. other Anemia- r/o ckd vs. other chronic dz vs. other Dehydration- r/o secondary to CKD Diarrhea- r/o primary GI vs. secondary to amoxiclav P: SQ fluids SID x 3 days Start Metronidazole Continue Amoxi/clav

Azotemia r/o primary renal vs. pre-renal Anemia r/o secondary to CKD vs. other chronic dz vs. other Neutrophilia- r/o infection vs. inflammation vs. neoplasia vs. other

Monitor patients dehydration S/O: BAR, eating well, SQF present. Clean litter. Allows all handling EENT: Pink moist mm, moderate dental tartar/gingivitis, nuclear sclerosis, no ocular or nasal discharge, ears WNL HL: Normal thoracic auscultation ABD: Soft, non tender INTEG: Unkemp MS: Ambulatory x 4 UG: Spayed A: R/O CKD P: Continue with current treatment and monitoring plan. Fair prognosis, will need long term care

Upon intake Persia was collared and her photo was taken.