POTATO BUN – 35598

DVM Intake Exam

Estimated age: Estimated 2-4 years old
Microchip noted on Intake? Scanned neg

History :

Subjective: Alert, mews, walks out of carrier with little encouragement

Observed Behavior – Allows all handling, moves slowly

Evidence of Cruelty seen – None

Evidence of Trauma seen – Large ulceration on nasal planum and muzzle, and on dorsal spine

Objective
BAR-H, MMs pink and moist, BCS 5/9
EENT: Large superficial ulceration on nasal planum and surrounding muzzle – approx 1 cm dia region, mild moist discharge. Eyes clear, ears clean, no ocular discharge noted.
Oral Exam: Clean adult teeth
PLN: No enlargements noted
H/L: NSR, NMA, Lungs clear, eupnic
ABD: Soft, non painful, no masses palpated, not distended
U/G: Male intact, testicles S/S
MSI: Patches of hypotrichosis and alopecia along the spine – two small areas of superficial ulceration in the middle, minimal moist discharge. 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: Wounds to nose and spine – suspect trauma

Prognosis: Good

Plan:
1. Onsior 0.4 ml SQ SID x3 days
2. Monitor wounds; at this time there is no indication that a systemic antibiotic is needed

SURGERY:
Okay for surgery