STYLEZ – 23645
Safe - 3-27-2018 Brooklyn
SAFE 3/27/18 STYLEZ is a 5 yr old neutered boy who was an owner surrender. He has the start of a URI and needs a new place to call home.
BROOKLYN CENTER
Stylez 23645
Location: Brooklyn
Intake Date: 3/24/18
Intake Type: Owner Surrender- ACO
Medical Behavior: Blue
Sex: Neutered
Age: 5 yrs
Weight: 15 lbs
Zip Code: 10007
Vet Notes: 2:31 PM
[DVM Intake]
DVM Intake Exam
Estimated age: approx 5 yo
Microchip noted on Intake? neg
Microchip Number (If Applicable):
History : o/s
Subjective: BAR. Nervous, like to hide, clings to table, but well behaved during PE and med handling. No signs of aggression
Observed Behavior –
Evidence of Cruelty seen – n
Evidence of Trauma seen – n
Objective
T =
P = wnl
R = wnl
BCS 6.5/9
EENT: Eyes clear, ears mild waxy debris, no nocular discharge noted. Serous nasal discharge bilaterally
Oral Exam: mild gingivitis and calculus
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic, no congestion
ABD: Non painful, no masses palpated
U/G: MN
MSI: 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
serous nasal discharge — suspect viral URI
Prognosis: good
Plan:
move to ISO
start fortiflora 1 packet SID x 7 days
give vit b12 0.25mL SQ once
vet check day 7
not starting abx at this time since dc is serous
SURGERY: neutered
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View all entries in: Safe Cats 2018-03