[DVM Intake] DVM Intake Exam Estimated age: Microchip noted on Intake? No History : Picked up as stray by the police, wound on left ear at LVT intake Subjective: Observed Behavior – Nice but became very squirmy and tried to get away from handler when trying to clean ear wound Kennel staff thinks p could be deaf- when approaching in cage p continued sleeping when his name was called, only responded when touched. Not able to assess hearing during exam Evidence of Cruelty seen – Evidence of Trauma seen – yes- wound on left ear Objective T = P = WNL R =WNL BCS 2.5/5 EENT: Mild mucoid dicscharge OU, yellow brown waxy debris in canals AU, several wound on left lateral ear margin and center of pinna on exterior and interior of pinna, full thickness laceration on lateral pinna, scabs and dried blood on ear near wounds, no nasal discharge Oral Exam: Clean teeth, mm pink PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: MI, sst MSI: Ambulatory x 4, skin free of parasites, no masses noted, several small scabs on dorsal thorax over shoulders, 1x2cm abrasion on dorsal tail about 1/3 the way from base CNS: Mentation appropriate – no signs of neurologic abnormalities Rectal: Not performed Assessment: Wounds on Left ear- r/o bite wounds vs. other Scabs on back- r/o additional wounds vs. pyoderma vs. other Abrasion on tail- r/o hot spot vs. other Prognosis: Good Plan: Cleaned ear wounds with chlorhex Cleaned both ear with ear cleaning solution Clavamox x 14 days Recheck ear wounds in 5 days If full thickness wound not healing by second intention may require surgical debridement and laceration repair E-collar SURGERY: Okay for surgery

Progress exam: CIRDC/re exam wounds History : Picked up as stray by the police, wound on left ear at LVT intake. DVM intakw 11/19-cleaned ears and wound on ear pinna and started on clavamox. Suspect deaf based on fact he does not respond to sound and must get his attention by touch. Subjective: BARH/ No c/v/d but is sneezing with mild serous nasal d/c and purulent ocular d/c. Objective P = WNL R =WNL BCS 3/5 EENT: purulent dicscharge OU with moderate conjunctivitis and blepharospasm, clean AU, mild serous nasal d/c and licking nose, AS has small superficial scab, AD pinna normal Oral Exam: Clean adult dentition, no oral ulcers PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic ABD: Non painful, no masses palpated U/G: MI, both testicles descended MSI: Ambulatory x 4, skin free of parasites, no masses noted, diffuse mild erythema, some some papules diffusely CNS: Mentation appropriate – no signs of neurologic abnormalities Assessment: CIRDC Deaf Small scab on left ear appears to be from scratching-ear was dirty yesterday and pruritic when cleaning, does not appear to be a puncture wound Scabs on back- r/o. pyoderma vs. other Abrasion on tail- r/o hot spot vs. other Prognosis: Good Plan: Move to iso Continue on clavamox until 12/3 Start doxycycline 10mg/kg PO SID x14d until 12/4 Start erythromycin OU BID x10d until 11/30 Start benadryl 2.2mg/kg PO BID x7d until 11/27 Recheck day 7