YONCE – 33645

DVM Intake Exam

Estimated age:4-5w
Microchip noted on Intake?no
Microchip Number (If Applicable):no

History :stray

Subjective:bar, underweight, eating very little

Observed Behavior – allows all handling

Evidence of Cruelty seen -no

Evidence of Trauma seen -no

Objective

T =
P =170
R = upper airway congestion
BCS – 1 1/2-2/5

EENT: eyes sealed, mucoid d/c ou w/ crusts around eyes and nose
Oral Exam: 4-5w
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G: fi
MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal:ne

Assessment: 4-5w dsh fi
1)conjunctivitis – viral vs bacteria
2)upper airway infection – r/o viral vs bacterial vs other
3)underweight

Prognosis:excellent

Plan:
1)nebulize w/ saline 15 minuetes bid
2)15 cc lrs sq
3)erythromycin bid x 7 days
4)doxycycline 3 mg po sid