SOX – 23255

DVM Intake Exam

Estimated age: reported 13y, exam corroburates
Microchip noted on Intake? none scanned

History :   owner surrender

Subjective: hiding in back of cage, when cage door opened approached and sought human contact

Observed Behavior – tractable and easily handleable

Evidence of Cruelty seen – none

Evidence of Trauma seen – none

Objective
8% dehydrated
T =
P = 200
R = wnl, eup
BCS 4/9

EENT: small amount of bilateral black crusty debris in the corners or eyes, ears clean, no nasal or ocular discharge noted
Oral Exam: halitosis, severe gingivitis and dental, missing incisors and moderate calculus
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G: neutered male
MSI: 2 cm x 2 cm area of alopecia with healing scab over scapula. muscle wasted 2/3 Ambulatory x 4, skin free of parasites- no flea dirt, no masses noted, healthy hair coat
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal: anus clean

Assessment:dehydrated, severe dental disease, under weight, alopecia (fleas v. other), suspect underlying disease

Prognosis: good

Plan:
1. submit cbc/chem for evaluation
2. 100 mL of LRS SQ- given during exam