SPENCER aka CATHERINE – 21548

DVM Intake Exam

Estimated age: 2yo
Microchip noted on Intake? neg
Microchip Number (If Applicable):

History : picked up from a hoarding case

Subjective: BAR. Friendly and well behaved during PE and med handling, no signs of aggression. A bit wiggly and difficult to restrain.

Observed Behavior –

Evidence of Cruelty seen – n

Evidence of Trauma seen – n

Objective

T =
P = wnl
R = wnl
BCS 5/9

MM pink and moist, normal skin turgor
EENT: OU third eyelids are raised, unsure if adhered to the corneas. Striated dark discoloration on both corneas, unable to view fundus. No obvious ulcers seen (did not stain). Ears have moderate amount of dry black/brown debris, pinna pedal reflex. No nasal discharge.
Oral Exam: nsf
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2 seconds. Lungs clear and eupnic
ABD: Non painful, no masses palpated. Moderately sized bladder, nonpainful
U/G: MI, 2 testicles, smooth and symmetrical
MSI: Ambulatory x 4, skin free of parasites, no masses noted, fair haircoat
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal: normal externally

Assessment:
Ocular disease
Ear mites

Prognosis: good

Plan:
Cleaned ears
Ivermectin 0.08mL SQ once
Terramycin ointment OU BID x 10 days
Plan for neuter
Recommend ophthalmologist consult asap

SURGERY:
ok for surgery

CAME IN WITH