WINTERGREEN – 9521

Staten Island Center

9521- Wintergreen – 9 week male – 2lbs – Blue Medical rating

10/11/17

L V T Notes: 7:58 PM

[LVT Intake Exam]

Microchip Scan:negative

Evidence of Cruelty:no

Observed Behavior:nervous , tense but allowed to handle

Sex:male

Estimated Age:2 months

Subjective: describe how he animal is apparently healthy

presenting and any known history

Eyes:wnl

Ears:wnl

Oral Exam:wnl

Abdomen:wnl

Musculoskeletal:wnl

 

10/12/17

Vet Notes: 6:05 PM

[DVM Intake]

DVM Intake Exam

Estimated age: 8 weeks

History : stray

Subjective:

Observed Behavior – hissing but tolerated exam

Evidence of Cruelty seen -no

Evidence of Trauma seen -no

Objective

BCS 4-5/9

EENT: OS- large amount of green mucoid discahrge and conjucntival hyperemia, OD- clear, AU-mild brown debris, no nasal discharge noted

Oral Exam: deciduous teeth

PLN: No enlargements noted

H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic

ABD: Non painful, no masses palpated

U/G: MI, only one testicle palpated

MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat

CNS: Mentation appropriate – no signs of neurologic abnormalities

Assessment

conjunctivitis OS

possible cryptorchid

Prognosis:good

Plan:

start erythromycin OS BID x 7 days

SURGERY:

Temporary waiver due to conjunctivitis

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