TIGGER – 34591

DVM Intake Exam

Estimated age: 15
Microchip noted on Intake? n
Microchip Number (If Applicable):
n
History : OS

Subjective: QAR, thrifty

Observed Behavior: Gentle

Evidence of Cruelty seen –
n
Evidence of Trauma seen –
n

Objective

T = –
P = 216
R = wnl
BCS – 3.75/9

EENT: Eyes clear, ears clean, Moderate Clear serous dis-charge nasal, no ocular discharge noted
Oral Exam: Dental disease
PLN: No enlargements noted
H/L: Referred upper respiratory sounds on auscultation of lungs, NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G: Neutered male
MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal: externally normal

CBC CHEMISTRY
– Mildly Increased Reticulocytes 60.9 – hemoconcentration
– Mild Elevation in glucose – 175 – Suspect stress
– Mild elevation in globulins – r/o inflammation vs infection

Assessment
– Blood work largely unremarkable – repeats in 6 months
– Moderate clear serous nasal dis-c
– Nasal congestion with referred Upper respiratory sounds on auscultation
– Dental disease

Prognosis: Fair

Plan:
Move to isolation
Complete intake tasks
General health panel – CBC/CHEM/T4

CAME IN WITH

Buddy 34590