CHLOE – 30508
Safe - 6-13-2018 Brooklyn Rescue: Feline Rescue of SI Please honor your pledges: http://felinerescueofstatenisland.org/donation/
SAFE 6/13/18 *DIABETIC & ANEMIC Cutie Calico CHLOE Needs You ASAP! **
Brooklyn Center
Chloe 30508 – 12 yr. female Calico:
KNOWN HISTORY:
Chloe was brought in as a stray, so we cannot speak to her behavior in her previous home.
MEDICAL BEHAVIOR:
06/07/18
Docile, lethargic
ENRICHMENT NOTES:
06/07/18
Tense and crouched on her blanket. Slow blinks and slowly turns head to sniff hand. Accepts gentle petting along body, tilts head slightly when rubbed on cheeks. Seems a little uncomfortable with a lot of attention. Kept interaction short.
Cage Condition:
Cage is slightly re-arranged
Reaction to assessor:
Chloe was lying down and curled up near the back of the kennel, with her tail wrapped around her body.
Reaction when softly spoken to:
Chloe lip licks, and turns her head slowly to make eye contact.
Reaction to cage door opening:
Chloe tenses up and becomes alert.
Reaction to touch:
Chloe’s pupils dilate and she hisses when the assessor’s extends his hand out. She sniffs his hand, and starts breathing rapidly, but tolerates slow, pets along her head and body.
ACTIVITY LEVEL:
Laid back
VOCAL:
Quiet
CHARACTER TYPE:
Timid
Independent
POTENTIAL CHALLENGES:
Fearful
Potential challenges comments:
Chloe has displayed fearful behavior during their stay in the care center and may dislike certain types of handling. A fearful cat will feel more relaxed when given options, so provide her with the chance to move closer, investigate, or interact with you. Be sure to offer incentive such as treats or play time whenever the cat makes a small positive step. Please speak to an adoption counselor for additional information on methods to desensitize your cat to their fear stimulus.
BEHAVIOR DETERMINATION:
Experienced, adult only
Behavior Asilomar
TM – Treatable-Manageable
RECOMMENDATIONS:
None
BEHAVIOR SUMMARY:
Please note that this cat has a severe medical condition so we may not be seeing any true behavior and behavior may change when the cat’s medical condition improves.
Chloe tolerates attention and petting but may be fearful or stressed in the shelter, and may be intimidated by small children. She may be a little more independent, and may need time to warm up to her new home. Due to the behaviors seen in the care center, we feel that this cat will do best in an experienced, adult only home.
This animal came from:
Found Stray
Origin Address
525 Putnam Avenue
Spay/Neuter status
Unknown
Date of Intake
6-Jun-2018
Is this cat having litter box issues?
No
If yes, Please elaborate:
Not applicable.
Basic Information:
The feline was brought in as a stray. Behavior is unknown.
Previously lived with:
The feline was brought in as a stray. Behavior is unknown.
How is this cat around strangers?
The feline was brought in as a stray. Behavior is unknown.
Surrendering client states that the feline attempted to scratch them.
How is this cat around children?
The feline was brought in as a stray. Behavior is unknown.
How is this cat around other cats?
The feline was brought in as a stray. Behavior is unknown.
How is this cat around dogs?
The feline was brought in as a stray. Behavior is unknown.
Behavior Notes
The feline was brought in as a stray. Behavior is unknown.
Surrendering client states that the feline attempted to scratch them.
Bite history:
The feline was brought in as a stray. Behavior is unknown.
Medical History Report
2336 Linden Boulevard
Brooklyn NY 11208
212-788-4000
Animal ID
Name
Type
Mixed
Color(1)
Color(2)
Gender
30508
Chloe
Cat
Yes
Calico
None
Female
Spayed / Neutered
Age
Primary Microchip #
Rabies Tag
Weight
Spay / Neuter Due Date
Temperature
No
12 Years
985113001791361
6 lbs 5.76 oz
Veterinary Clinic Software Record #:
Weight: 6 lbs 5.76 oz
Date of Weighing: 6/6/2018
Date Spayed / Neutered:
Schedule Surgery Date:
Stitches Removal Date:
Clinic Name:
Previously Spayed / Neutered: No
General Vet Notes:
Previous Medical Details:
Known Allergies or Medical Conditions:
Feeding Requirements:
Indemnities/Waivers:
Medical Notes
Notes
Date
No Medical Notes Stored
Vet Treatments
Date Administered
Vet Treatment Type
Treatment Result
Administered by External Vet
6/7/2018
Microchip Implantation
6/7/2018
Gabapenth (50 Mg/Ml)
6/7/2018
Re-weigh
6/7/2018
Rabies
6/7/2018
Internal Parasite Treatment – Pyrantel
6/7/2018
Fvr-Cp 1 Of 2
6/7/2018
Flea/Tick Application – Topical
6/7/2018
FeLV/FIV Snap
Negative
Vet Treatments Due
Date Due
Vet Treatment Type
6/21/2018
Fvr-Cp 1 Of 2
6/21/2018
Internal Parasite Treatment – Pyrantel
6/21/2018
Re-weigh
7/7/2018
Flea/Tick Application – Topical
6/7/2019
Rabies
Medications
Medication
Amount Dispensed
Frequency
Date From
Date To
Doses Administered
Vet Name
Reason
Notes
ProZinc Insulin U40
0
1, 2 times every 1 day(s)
8-Jun-2018
Indefinite
4
VET-P 991027
1 unit sq BID U=40 syringe. Make sure eating before administering. Get BG prior to administration. If BG<300, DO NOT ADMINISTER AND CALL DVM.
Fluids – LRS SQ
0 ml
100, 2 times every 1 day(s)
7-Jun-2018
Cancelled 8-Jun-2018
2
VET-P 991027
100 cc lrs sq bid
Amoxicillin/Clavulanic Acid Drops 62.5 mg/ml
0 ml
1, 2 times every 1 day(s)
7-Jun-2018
After 20 occurrences
5
1 ml po bid
Cerenia (Maropitant) INJ 10 mg/ML
0.9 ml
0.3ml every 1 day(s)
8-Jun-2018
10-Jun-2018
3
VET 991524
Give 0.3ml SQ once a day
Fluids – LRS SQ
320 ml
40mls, 2 times every 1 day(s)
9-Jun-2018
Cancelled 10-Jun-2018
3
VET 991524
Give 40mls SQ twice a day
Drug Usage
No drugs administered to this animal.
Vet Consultations
Date
Reasons
Vet Notes
Vet
Date Resolved
10-Jun-2018
Progress Exam
Vet Notes: 2:05 PM
H: Intake on 6/7. Stray, reported polydipsic. anorexic, weak. ate at ACC
CBC/Chem/T4:
CBC- Mild anemia (Hct 29.5%), mildly regenerative (59.1K), leukocytosis (29.5), Neutrophilia (15.65),
Chem- Hyperglycemia (345), mild elevation in BUN (51), Elevation in LES: ALT 529, ALP 180, GGT 5
urine dipstick shows glucose >1000, +++ ketones. leukocytes in urine.
Given 2 units PZI at 130pm, started on 1U Prozinc SQ BID
S: QAR to BAR. Adequate hydration. No csvd. Mod amount of urine. No BM. Ate half of wet food. Hissing and swatting.
CRT: <2s. Gums: pink
Eyes: Grossly appropriate OU.
Ears: Unremarkable AU.
Nasal Cavity: No nasal discharge.
Oral Cavity: moderate dental tartar/periodontal disease
PLN: WNL
Heart: Gallop rhyhtym ausculted with Grade II systolic murmur ausculted. Pulses adequate bilaterally
Lungs: Eupneic, lungs clear. No crackles or wheezes bilaterally.
Abd: Soft, non-painful doughy abdomen. No palpable masses. No organomegaly appreciated.
U/G: Normal external genitalia. No discharge.
Musculoskeletal: Ambulatory x 4 with no appreciable lameness.
BCS = 6/9
Integument: roughened haircoat
Neuro: Appropriate mentation. Full neurologic exam not performed.
Rectal: Not performed. Externally normal.
Assessment:
1) Diabetic Ketosis (DK)- unable to determine if DKA as unable to measure pH on bloodwork. r/o common comorbidites such as UTI/pyelonephritis, pancreatitis, etc.
2) Mildly regenerative anemia- given the minimal regenerative response, cannot r/o causes for non-regenerative anemia (anemia of chronic disease, renal disease , neoplasia) vs causes for regenerative anemia (infectious vs IMHA vs less likely toxin, hemorrhage)
3) Elevated LES r/o diabetic hepatopathy vs cholangiohepatitis vs neoplasia less likely neoplasia
4) Gallop rhythym + murmur- r/o secondary to underlying heart disease (HCM)/excessive fluid administration
6/8: AM BG 429 (not eating), gave 0.5 prozinc; PM BG 390 (eating), given 1 U
6/9: AM BG 428 (eating), gave 1U; PM BG 429 (not eating), given 0.5U prozinc
6/10 AM BG 511 (did not eat in the moment, but food gone from last night), 1U prozinc given
Prognosis: Guarded
Plan:
Continue 1U Prozinc BID, obtain BG prior to insulin administration- if not eating or if BG<300, do not administer and call Dr.
d/c fluids at this time
last day maropitant
Continue Clavamox until 6/16
Seek NH placement- needs AUS, urine culture to further assess for underlying comorbidities for diabetes.
VET 991524
9-Jun-2018
Progress Exam
Vet Notes: 3:33 PM
H: Intake on 6/7. Stray, reported polydipsic. anorexic, weak. ate at ACC
CBC/Chem/T4:
CBC- Mild anemia (Hct 29.5%), mildly regenerative (59.1K), leukocytosis (29.5), Neutrophilia (15.65),
Chem- Hyperglycemia (345), mild elevation in BUN (51), Elevation in LES: ALT 529, ALP 180, GGT 5
urine dipstick shows glucose >1000, +++ ketones. leukocytes in urine.
Given 2 units PZI at 130pm, started on 1U Prozinc SQ BID
S: QAR to BAR. No csvd. Mod amount of urine. No BM. Most of wet food gone. Hissing and swatting- visual only performed
Eyes: Grossly appropriate OU.
Ears: Unremarkable AU.
Nasal Cavity: No nasal discharge.
Lungs: Eupneic
U/G: Normal external genitalia. No discharge.
Musculoskeletal: Ambulatory x 4 with no appreciable lameness.
BCS = 6/9
Integument: roughened haircoat
Neuro: Appropriate mentation. Full neurologic exam not performed.
Rectal: Not performed. Externally normal.
6/8: AM BG 429 (not eating), gave 0.5 prozinc; PM BG 390 (eating), given 1 U
6/9: AM BG 428 (eating), gave 1U
Assessment:
1) Diabetic Ketosis (DK)- unable to determine if DKA as unable to measure pH on bloodwork. r/o common comorbidites such as UTI/pyelonephritis, pancreatitis, etc.
2) Mildly regenerative anemia- given the minimal regenerative response, cannot r/o causes for non-regenerative anemia (anemia of chronic disease, renal disease , neoplasia) vs causes for regenerative anemia (infectious vs IMHA vs less likely toxin, hemorrhage)
3) Elevated LES r/o diabetic hepatopathy vs cholangiohepatitis vs neoplasia less likely neoplasia
4) Gallop rhythym- r/o secondary to underlying heart disease (HCM)/excessive fluid administration
Prognosis: Guarded
Plan:
Continue 1U Prozinc BID, obtain BG prior to insulin administration- if not eating or if BG<300, do not administer and call Dr.
Continue LRS SQ administration to 40mls SQ BID
Continue Maropitant 1 mg/kg SQ SID x 3 days, then re-eval
Continue Clavamox until 6/16
Seek NH placement- needs AUS, urine culture to further assess for underlying comorbidities for diabetes.
VET 991524
8-Jun-2018
DVM Intake
Vet Notes: 2:49 PM
H: Intake on 6/7. Stray, reported polydipsic. anorexic, weak. ate at ACC
CBC/Chem/T4:
CBC- Mild anemia (Hct 29.5%), mildly regenerative (59.1K), leukocytosis (29.5), Neutrophilia (15.65),
Chem- Hyperglycemia (345), mild elevation in BUN (51), Elevation in LES: ALT 529, ALP 180, GGT 5
urine dipstick shows glucose >1000, +++ ketones. leukocytes in urine.
Given 2 units PZI at 130pm, started on 1U Prozinc SQ BID
S: QAR to BAR. ~5-6% dehydrated. No csvd. Mod amount of formed stool. Large amount of urine in cage. NI in food this morning (ate a small amount of tuna prior to insulin administration)
CRT: <2s. Gums: pink, tacky
Eyes: Grossly appropriate OU.
Ears: Unremarkable AU.
Nasal Cavity: No nasal discharge.
Oral Cavity: moderate dental tartar/periodontal disease
PLN: WNL
Heart: Quiet gallop rhyhtym ausculted. Pulses adequate bilaterally
Lungs: Eupneic, lungs clear. No crackles or wheezes bilaterally.
Abd: Soft, non-painful doughy abdomen. No palpable masses. No organomegaly appreciated.
U/G: Normal external genitalia. No discharge.
Musculoskeletal: Ambulatory x 4 with no appreciable lameness.
BCS = 6/9
Integument: roughened haircoat
Neuro: Appropriate mentation. Full neurologic exam not performed.
Rectal: Not performed. Externally normal.
BG: 429
Since not eating well this morning, only 0.5U prozinc given this morning
Assessment:
1) Diabetic Ketosis (DK)- unable to determine if DKA as unable to measure pH on bloodwork. r/o common comorbidites such as UTI/pyelonephritis, pancreatitis, etc.
2) Mildly regenerative anemia- given the minimal regenerative response, cannot r/o causes for non-regenerative anemia (anemia of chronic disease, renal disease , neoplasia) vs causes for regenerative anemia (infectious vs IMHA vs less likely toxin, hemorrhage)
3) Elevated LES r/o diabetic hepatopathy vs cholangiohepatitis vs neoplasia less likely neoplasia
4) Gallop rhythym- r/o secondary to underlying heart disease (HCM)/excessive fluid administration
Prognosis: Guarded
Plan:
Continue 1U Prozinc BID, obtain BG prior to insulin administration- if not eating or if BG<300, do not administer and call Dr.
Decrease fluid administration to 40mls SQ BID
Added Maropitant 1 mg/kg SQ SID x 3 days, then re-eval
Continue Clavamox until 6/16
Seek NH placement- needs AUS, urine culture to further assess for underlying comorbidities for diabetes.
VET 991524
7-Jun-2018
Blood Work Interpretation
Vet Notes: 1:31 PM
Bg 345
elevated les (likely diabetic hepatopathy)
urine dipstick shows glucose >1000, +++ ketones. leukocytes in urine.
gave 2 units PZI at 130pm
will start on 62.5mg clavamox bid
PZI starting tomorrow 1 unit bid
100cc lrs sq bid
bg tomorrow AM
VET-P 991027
7-Jun-2018
Spay-Neuter Waiver Documentation
Vet Notes: 12:50 PM
[Spay/Neuter Waiver – Age]
It is the policy of ACC not to perform surgery on any animal over the age of 8-10 years due to the higher risks incurred in a shelter setting. The veterinarian is hereby issuing a permanent spay/neuter waiver, from the spay/neuter requirements of the City of NY due to the estimated age of this animal. ACC does recommend you consult with your veterinarian to determine if surgical sterilization is appropriate.
VET-P 991027
7-Jun-2018
7-Jun-2018
DVM Intake
Vet Notes: 12:25 PM
[DVM Intake]
DVM Intake Exam
Estimated age:12y
Microchip noted on Intake?n
Microchip Number (If Applicable):
History :stray, reported polydipsic. anorexic, weak. ate at ACC
Subjective:doughy abdomen, increased skin tent. plae pink gums
Observed Behavior -docile, lethargic
Evidence of Cruelty seen -n
Evidence of Trauma seen -n
Objective
T =
P =120
R =wnl
BCS 5/9
EENT: aging chanes to eyes, ears clean, no nasal or ocular discharge noted
Oral Exam:heavy dental tartar
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G: female, did not shave
MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat
CNS: lethargy
Assessment: open. rule out renal dz, daibetes
Prognosis:guarded
Plan:cbc/chem/t4
SURGERY:
Permanent waiver due to age
VET-P 991027
6-Jun-2018
LVT Intake
L V T Notes: 8:42 PM
[LVT Intake Exam]
Microchip Scan: Negative
Evidence of Cruelty:None
Observed Behavior: Little nervous, tolerated handling
Sex:Female
Estimated Age:12 years
Subjective: describe how he animal is presenting and any known history– Chloe came in as a stray,unknown medical hx
Eyes: clear, no ocular discharge
Ears: clean
Oral Exam: moderate tartar, gingivitis
Heart: HR=160
Lungs: 24
Abdomen:distended,tense
Musculoskeletal: Dehydrated, unkept coat
Mentation:
Preliminary Assessment: Dehydrated, geriatric
Plan: Per on call vet:
T=99.3F
– 200cc LRS s/C
– CBC/Chem/UA — to be done tomomorrow
-DVM intake exams.
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