TIDE – 25187

[DVM Intake]
DVM Intake Exam

Estimated age: 6
Microchip noted on Intake? n
Microchip Number (If Applicable):

History :

Subjective: Dull, obtunded, head depressed, 3% dehydrated

Observed Behavior – allows for PE, did attempt to bite glove when moving front legs

Evidence of Cruelty seen – n

Evidence of Trauma seen – n

Objective

T = –
P = 180
R = wnl
BCS = 3.5/9

EENT: dried nasal dis-c with mild nasal congestion, OR conjunctivitis with elevated nictating membranes, ears pruritic with moderate brown greasy waxy debris

Oral Exam: edentulism, peridontitis
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G: Male Neutered
MSI: MSK reflexes normal (withdrawal, placement reflex), Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat
CNS: Paresis vs obtunded, head pressing on floor of kennel
Rectal: externally normal

Assessment:
– URI
– Paresis vs obtunded ? (head depressed to kennel floor)
– Dehydrated 3%
– Otitis externa

Prognosis: poor to fair

Plan: Provide supportive treatment and monitor for response

IVF fluids – 2 x maintenance
Erythromycin eye ointment OR for 7 days
Doxycycline 10mg/kg SID for 10 days
Tresaderm BID for 10 days
Vit B complex 0.3 ml SQ

CBC – Chemistry