SNUBBY – 10618

DVM Intake Exam

Estimated age: 4-8 years based on overall appearance
Microchip noted on Intake? Scanned neg on intake

History : Stray, appeared sick

Subjective: Sitting with head down, not moving.

Observed Behavior – Slightly tense, allows all handling

Objective
QAR, estimated 10% dehydrated based on sunken eyes and decreased skin turgor. BCS 3.5/9
EENT: OU moderate mucoid discharge. Nose is crusted over with thick yellow discharge.
Oral Exam: Halitosis. Thick grey mucoid discharge on teeth, distal tongue is ulcerated and erythematous.
H/L: NSR, NMA, Obstructed upper resp sounds, increased resp effort.
ABD: Doughy abdomen.
U/G: Female intact.
MSI: Ambulatory x 4, Ocular and nasal discharge crusted onto legs.
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal: Normal externally

Assessment:
1. Dehydrated
2 URI and conjunctivitis
3. Severe oral infection

Prognosis: Poor to guarded

Plan:
1. Administered the following treatments at 10am:
-100 ml SQ LRS with 0.25 ml vit B12
-Simbadol 0.25 ml SQ
-Doxycycline 0.4 ml PO
-Erythromycin OU
-Cerenia 0.2 ml SQ
-Nebulize with gentamicin
2. Start the following:
-200 ml LRS SQ x5 days
-Doxycycline 0.4 ml PO SID x10 days
-Cerenia 0.2 ml SQ x3 days
-Erythromycin OU BID x10 days
-Nebulize with saline

SURGERY:
Temporary waiver due to URI