PETRA BEST – 19407

DVM Intake Exam

Estimated age:8-9 weeks
Microchip noted on Intake?neg
Microchip Number (If Applicable):

History :litter of 5 kittens found in a basement; 2 kittens have alopecic lesions on head that are suspicious of ringworm

Subjective:QAR

Observed Behavior -slightly unsocialized but allows handling; hissed once

Evidence of Cruelty seen -n

Evidence of Trauma seen -n

Objective
BCS 4.5/9

EENT: Eyes clear, AU-clean, nonpruitic, no nasal or ocular discharge noted
Oral Exam:mm lgt pk/pk, moist; deciduous dentitia
PLN: No enlargements noted
H/L: eupnic, normal lung sounds; no murmurs/arrhythmias
ABD: Non painful, no masses palpated
U/G: female intact
MSI: Ambulatory x 4, flea debris, no masses noted, 1-1.5 inch area of alopecic area on top of head with mild crusting but appears quiet otherwise; one focal area of crusting glows wood’s lamp positive; mildly thin hair coat periocularly OD, small area dorsally that glows positive
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal:grossly normal

Assessment
1. suspect ringworm
2. Flea debris

Prognosis:good with treatment

Plan:
-treated with topical frontline spray
-DTM culture started from litter
-treat as ringworm pending DTM culture
-itrafungol 0.4 ml PO SID x 21 days
-rec’d lime sulfur dips twice weekly until DTM culture neg

SURGERY:temp waiver due to possible ringworm exposure

CAME IN WITH

John Lennon 19405

Paul McCartney 19406

Ringo Starr 19408

Georgia Harrison 19409