TUXEDO – 12968

DVM Intake Exam

Estimated age: older male cat, ~ 8-10 yrs
Microchip noted on Intake? scan negative

History : stray, ear-tipped feral

Subjective: QARH

Observed Behavior – calm, timid will flee but allowed all handling
Evidence of Cruelty seen – no
Evidence of Trauma seen – laceration to lateral right elbow

Objective
HR/RR – wnl
BCS 7/9

EENT: OU clean/clear; AS ear-tipped, AU mild dary waxy d/c; no nasal or ocular discharge noted
Oral Exam: limited due to sensitive/fighting exam – only has 304 canine, miss rest with mod dental dz
PLN: No enlargements noted
H/L: nsf; NSR, NMA, CRT < 2; Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G: neutered male
MSI: Ambulatory x 4, mod dirty coat/dry seborrhea, open laceration ~ 2×2 cm at lateral side of right elbow, no discharge, necrotic/non healing edges; no masses noted, no parasites observed
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal: externally normal

A: calm feral with open, non-healing skin wound to lateral right elbow

P: gave 0.54 ml convenia SQ
– simbadol 0.75 ml SQ x 5 days
– wound clean/repair under sedation and rabies vax

Prognosis: good

SURGERY: neutered