ANGEL – A0686671 aka ANTONIO aka ANTIONIO – A1115340
Gone - 6-16-2017 Brooklyn
ANGEL – A0686671 (aka ANTONIO) aka ANTIONIO – A1115340
NEUTERED MALE, GRAY, DOMESTIC SH MIX,15 yrs
STRAY – STRAY WAIT, HOLD FOR ID Reason STRAY
Intake condition ILLNESS Intake Date 06/14/2017, From NY 11206, DueOut Date 06/19/2017,
Medical Behavior Evaluation GREEN
Medical Summary DVM Intake Exam Estimated age: 15 Microchip noted on Intake? 0A10226828 History : unknown Subjective: Dull . Marked dehydration- tent does not go down. Observed Behavior – Allows handling but did paw my hand away while examining mouth Evidence of Cruelty seen – n Evidence of Trauma seen – n Objective T = P = 128 R = eup BCS= 2/9 EENT: Eyes sunken, MPOD, PLR, lenticular sclerosis. Ears clean, no nasal discharge noted Oral Exam: marked tartar, purulent discharge in mouth but no masses, salivating PLN: No enlargements noted H/L: bradycardia, NMA, MM pale pk, CRT 2+, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: male neutered, small kidneys MSI: Ambulatory x 4, skin free of parasites, no masses noted, dry unkempt hair coat CNS: mentation dull but no signs of neurologic abnormalities Rectal: n Assessment: Severe dehydration. CRF – severe. Unable to concentrate urine despite severe dehydration. Severe dental dz. Salivating – r/o due to nausea/ renal dz vs ddz. Bradycardia – r/o dehydration. Plan: Urine via cysto – SpGr= 1.016. Dipstick – blood 50, protein 500, pH 5, leukocytes 500. SQF 150 cc. Simabadol Pen G 0.3 cc sq. Clavamox 0.6 cc po bid x 10 d. monitor app. Monitor if eats with pain medication and SQF. If not improving, consider EHR. Consider BW to confirm renal failure. Prognosis: Grave.
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