PRINCESS LIMA BEAN – 23241

PRINCESS LIMA BEAN – 23241

Intake Date : 3/19/18  Intake Type: Stray

Medical Behavior: Yellow  Age: 5 years  Sex: Female

Weight: 52 lbs

DVM Intake Exam : Estimated age: 3-8 years based on dentition and overall impression  Microchip noted on Intake? Scanned negative – MC placed  History : No health hx available  Subjective: Alert, whining when unattended  Observed Behavior – Tense, nervous, jumps around occasionally but allows all handling. Muzzled for safety.  Evidence of Cruelty seen – None  Evidence of Trauma seen – None  Objective :  BAR-H, MMs pink and moist, BCS 5/9  EENT: AU mild yellow discharge, mild lichenification. AD aural hematoma developing in the distal 1/3 of the pinna; pinna is erythematous and warm. Eyes clear, no nasal or ocular discharge noted  Oral Exam: Muzzled. Incisors are very clean.  PLN: No enlargements noted  H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic  ABD: Soft, non painful, no masses palpated  U/G: Female, pendulous nipples, developed vulva. No masses or discharge noted.  MSI: Small erythematous alopecic lesions on the medial aspect of pt’s carpi and feet. Mild spotty alopecia on dorsum. Skin free of parasites, no masses noted.  CNS: Mentation appropriate – no signs of neurologic abnormalities  Rectal: Normal externally  Assessment:  1. Otitis externa with small aural hematoma AD  2. Lesions on pt’s feet – R/O traumatic/related to sleeping on rough surfaces  Prognosis: Good  Plan:  1. Cleaned ears and administered Osurnia AU – repeat in 7 days  2. Rimadyl 100 mg PO SID x5 days  SURGERY:  Okay for surgery

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