[DVM Intake]P9991444 DVM Intake Exam Estimated age: 7-9 yrs – based on eyes and teeth Microchip noted on Intake? Y History : Stray Subjective: BAR, observed by tech staff to be straining to urinate Observed Behavior -scared and likely painful OD, resents exam around head Evidence of Cruelty seen – N Evidence of Trauma seen – N Objective T = P = 140 R = panting BCS 2 1/2-3/5 EENT: OD – ruptured globe w/ discharge, corneal edema, scleral injection, OS – pigmentary keratitis and mild scleral injection, ears clean, no nasal or ocular discharge noted Oral Exam: mod tarter – quick assessment PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful/tense, no masses palpated U/G: fi multiple mammary masses 2 caudalmost mg’s bilaterally, prominent vulva MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat CNS: Mentation appropriate – no signs of neurologic abnormalities Rectal: NA Assessment: 7-9 yr fi mixed breed OD – ruptured globe – secondary to chronic kcs, uveitis, glaucoma vs primary injury/trauma OS – pigmentary keratitis r/o kcs vs glaucoma vs uveitis vs other mammary tumors – r/o benign (intact) vs malignant dental tarter UTI – r/o bacterial vs stone vs other Prognosis: OD – poor for saving eye, enucleation likely needed OS – good, but r/o underlying dz Mammary tumors – good to excellent if removed and ovh’d dental tarter – excellent if dental uti – good to excellent Plan: rimadyl for pain 1/2 25mg po bid w/ meals gabapentin 25 mg po bid clavamox 62.5mg po bid x 7 days stt, fluorescein stain, +/- tonometry – may need sedation to allow cbc/chem urine strip – 2-3+ protein, 3-4+ protein, 1-2+ Leukocytes, Neg glucose SURGERY: Temporary waiver due to underlying eye condition and further evaluation

SURGERY IS TEMPORARILY WAIVED FROM ACC DUE TO EYE RUTURED.

Globe rupture OS, heart murmur, straining to urinate; blood work available for review S/O -BAR, energetic and allows handling but resists restraint for blood draw and ocular exam -mm pk, sl tacky; CRT <2 sec -OD: previous globe rupture with mucoid plug mid field; severe corneal edema, blepharospasm, elevated 3rd eyelid -OS: pigmentation in anterior chamber, possible immature cataract -eupnic; grade V L sided heart murmur -mild pot bellied appearance, cranial organomegaly A Globe rupture OS Suspect KCS Heart murmur Bladder stone-suspect calcium oxalate Hepatomegaly-r/o Cushing’s disease vs other Mildly elevated ALP-r/o cushing’s disease vs benign elevation vs other P -Sedated with 0.2 ml torb/0.3 ml valium IV for radiographs and STT -Ofloxacin OD QID, recommend treating hourly but unable to accomodate in shelter -CWCT -Recommend consult with ophthalmologist ASAP to discuss treatment of previous globe rupture OD -Recommend low dose dexamethasone test to r/o cushing’s disease -Recommend cystotomy with stone analysis

Blood work and radiographs available for review CBC-mild monocytosis, severe thrombocytosis (780) Chemistry-mild elevated globulins (4.6) and ALP (244) STT-12 mm/min OS, 14 mm/min OD 2 view full body radiographs-large stellate shaped bladder stone; liver enlarged, edges rounded, no obvious mass; mild cardiomegaly A 1. Mild monocytosis-r/o chronic condition 2. Thrombocytosis-r/o Cushing’s disease vs other 3. Mild elevated ALP-r/o benign elevation vs Cushing’s vs other 4. Possible KCS, would expect STT to be increased due to severe ocular disease 5. Hepatomegaly-r/o Cushing’s disease vs other 6. Bladder stone-r/o calcium oxalate vs struvite P see medical notes below

Support staff worried that p has not urinated. Abd : soft nonpainful, no overt masses, bladder palpates small and nonpainful. P: ctm to make sure p is urinating. Vet recheck tomorrow.

Pt pawing at ruptured eye a lot. Restart gabapentin – 0.75 ml PO BID x10 days. 1088

Upon intake, Granny Smith was interested in her surroundings. She allowed counselor to pet, collar, and pick up.