[DVM Intake] DVM Intake Exam DVM 1431 Estimated age:9 years Microchip noted on Intake? yes History : stray Subjective: BAR, hydrated Observed Behavior – Friendly, allows exam and treatment with minimal restraint. Evidence of Cruelty seen -no Evidence of Trauma seen -no Objective P = 120 R = wnl BCS: 5/9 EENT: Eyes clear, ears clean, no nasal or ocular discharge noted Oral Exam: mild tartar PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: male intact, both testes descended and symm. MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat CNS: Mentation appropriate – no signs of neurologic abnormalities Assessment: geriatric with mild periodontal disease In good health otherwise Prognosis: good Plan: continue to monitor at ACC SURGERY: Permanent waiver due to age

Monitor for diarrhea S/O: BAR. Active, attention seeking in cage. Eating well. No diarrhea seen or reported EENT: Nuclear sclerosis, no ocular or nasal discharge HL: No coughing or sneezing A: Geriatric, dental disease P: Continue to monitor while at BACC. Good prognosis

Diarrhea noted on rounds board 10/14 and 10/8. Hematuria noted 10/19 S/O: QAR. Active. Eating well. No c/s/v/d EENT: Nuclear sclerosis, no ocular or nasal discharge HL: No coughing or sneezing A: Geriatric Intermittent Diarrhea Hematuria Dental disease P: Continue to monitor while at BACC. CBC 10/22 Chem 10/22 2 view AXR 10/22 UA 10/22 Start metronidazole 15mg/kg PO BID x5d Recheck diarrhea in 5 days Good prognosis

Diarrhea noted on rounds board 10/14 and 10/8. Hematuria noted 10/19 S/O: QAR. Active. Eating well. No c/s/v/d. Objective P = wnl R = eupneic BCS 6/9 EENT: Eyes clear with nuclear sclerosis ou, ears clean, no nasal discharge noted Oral Exam:adult dentition with dental disease, no oral lesions noted PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic ABD: Non painful, no masses palpated U/G: MN MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat CNS: mentation appropriate – no signs of neurologic abnormalities Rectal: unable to palpate prostate, nsf A: Geriatric Intermittent Diarrhea Hematuria r/o prostatitis Dental disease Soft tissue opacity in caudal abdomen r/o prostate vs mass vs other Elevated ALP Hyperglobulinemia WBC in urine Proteinuria P: Continue to monitor while at BACC. CBC-pending when machine is functional Chem-Elevated ALP 559 (23-212), hyperglobulinemia 5.4 (2.5-4.5) 2 view AXR-large soft tissue mass in caudal abdomen caudal to bladder, no other abnormalities UA-urine is purulent with red tinge, USG 1.32, RBC 250, Protein 500, Nitrite faint positive, pH 7, WBC 500 Continue metronidazole 15mg/kg PO BID Start baytril 10mg/kg PO SID x14d for prostatitis Recheck 7, 10 d Good prognosis

Vomited twice 10/23 History: Diarrhea noted on rounds board 10/14 and 10/8-started on metronidazole. Hematuria noted 10/19 10/22: CBC-pending when machine is functional Chem-Elevated ALP 559 (23-212), hyperglobulinemia 5.4 (2.5-4.5) 2 view AXR-large soft tissue mass in caudal abdomen caudal to bladder, no other abnormalities UA-urine is purulent with red tinge, USG 1.32, RBC 250, Protein 500, Nitrite faint positive, pH 7, WBC 500 S/O: BAR. Active. Eating well. No c/s/v/d noted on rounds. Objective EENT: Eyes clear with nuclear sclerosis ou, no nasal discharge noted H/L: No c/s A: Geriatric Intermittent Diarrhea Vomiting Hematuria r/o prostatitis Dental disease Soft tissue opacity in caudal abdomen r/o prostate vs mass vs other Elevated ALP Hyperglobulinemia WBC in urine Proteinuria P: Continue to monitor while at BACC. Continue metronidazole 15mg/kg PO BID until 10/26 Continue baytril 10mg/kg PO SID for prostatitis until 11/5 LRS 20ml/kg SQ once Cerenia 1mg/kg SQ once Recheck tomorrow Good prognosis

Monitor for vomiting S/O: BAR. Attention seeking. Good appetite. No vomit or diarrhea seen or reported EENT: Nuclear sclerosis, no ocular or nasal discharge HL: No coughing, normal RR/RE A: Geriatric, one episode of vomiting reported, none seen today, on treatment for diarrhea and UTI, mass effect at caudal abdomen – R/O prostate vs mass P: Continue with current treatment and monitoring plan. Rec repeat blood work and urinalysis after course of antibiotics. Consider abdominal ultrasound. Good/fair prognosis

Disregard

Sedated with 0.9cc Dex/1.1cc Torb IV. CBC/Chem Bloods drawn – malfunction of IDEXX machine – Chemistry only 6 AXR rads- 3RL, 3VD Urinalysis taken through sterile tube. All results given to Dr. RW

Walter was relaxed upon intake. allowed all handling.