Vet AI Scribe for Shelter Medicine

Willow

Monday, February 3, 2025 at 8:15 AM

Intake exam — stray hold, kennel B-14

Subjective

Chief Complaint

Intake examination of an adult female cat surrendered as a stray by a member of the public. Sneezing and ocular discharge noted by intake staff at the front counter.

History

• Found in a residential area; no known owner; no microchip detected on two-direction scan.
• Estimated age 2-4 years on dentition.
• No vaccination history available.
• Shelter is currently at 84% of feline capacity; isolation ward has 3 of 8 runs occupied.
• Two upper respiratory cases confirmed in the general population in the past 10 days.

Objective

Vitals

• Weight: 3.1 kg; body condition 3/9
• Temperature: 102.9°F
• Heart rate: 192 bpm
• Respiratory rate: 40 breaths/min

Physical Exam

• Eyes: Bilateral serous to mucoid ocular discharge; mild conjunctival hyperaemia; no corneal ulceration on fluorescein stain
• Nares: Bilateral serous nasal discharge; sneezing observed during exam
• Oral: Mild gingivitis; no ulceration of the tongue or palate
• Lymph nodes: Mandibular nodes mildly enlarged bilaterally
• Respiratory: Referred upper airway sounds; lung fields clear
• Abdomen: Soft; no masses; no uterine enlargement palpable
• Integument: Flea dirt over the tail base; no alopecia; ears with mild dark debris
• Reproductive: No spay scar found; no ear tip; mammary chain quiescent

Point-of-Care Diagnostics

• FeLV antigen / FIV antibody: Negative / negative
• Ear cytology: Otodectes mites seen
• Fluorescein stain: Negative both eyes

Assessment

Individual Problem List

1. Feline upper respiratory infection, mild — no ulceration, eating on presentation
2. Otoacariasis
3. Flea infestation
4. Underweight — body condition 3/9
5. Unknown reproductive status — no spay scar, no tattoo

Population Considerations

This is the third upper respiratory case in ten days. The relevant question is not only how to treat this cat but whether the shelter is seeing sporadic stress-related recrudescence of latent herpesvirus or an active transmission chain. Isolation capacity is adequate today; at current intake rates it will not be in a week.

Differentials

• Feline herpesvirus-1 — most common, typically with ocular signs
• Feline calicivirus — oral ulceration absent, which argues against it
• Chlamydia felis — conjunctivitis often more marked
• Mycoplasma sp. or Bordetella bronchiseptica

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Plan

This Animal

• Housing: Isolation ward, run I-3. Handled last on the daily round; dedicated gown and gloves.
• Vaccination: FVRCP and rabies given at intake — vaccinate on arrival, not on discharge
• Parasites: Topical selamectin, covering fleas and ear mites in one application
• Deworming: Pyrantel; repeat in 14 days
• Microchip: Implanted and registered to the shelter
• Nutrition: Highly palatable diet, fed in a quiet run; weight recorded every 48 hours
• Antibiotics: Withheld. Signs are mild and viral aetiology is most likely; reassess if pyrexia persists past 72 hours, discharge becomes mucopurulent, or appetite falls off.
• Stray hold: 5 days per local ordinance; photograph posted to the found-pet listing today

Population Management

• Review the three recent cases for a common kennel block, feeding order or handler
• Confirm intake vaccination is happening at the counter rather than at the medical exam
• Audit cleaning sequence: isolation last, separate equipment
• Report daily isolation occupancy to the operations lead; escalate if occupancy exceeds 6 of 8

Follow-Up

• Daily rounds while in isolation; temperature and appetite recorded
• Release from isolation after 48 hours free of clinical signs
• Spay and behaviour assessment scheduled at the end of the stray hold if unclaimed

Client Communication:
Not applicable at intake. Notes prepared for the adoption record: this cat has had an upper respiratory episode, and herpesvirus is lifelong and can recur at times of stress, including the move to a new home. Adopters should be told this plainly so a sneezing cat in week one is not read as a failed adoption.

— Dr. Tessa Lindqvist, DVM, DABVP (Shelter Medicine Practice)