CLOVER – A1114554
Urgent - Manhattan
GETTING TREATMENT – FOSTER CARE – CLOVER was found in a basement – she was not eating and vomited – brought to shelter – she is pregnant and may have open pyometra – needs further medical.
CLOVER – A1114554
FEMALE, GRAY TABBY, DOMESTIC SH MIX,2 yrs
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition PREGNANT Intake Date 06/07/2017, From NY 10460, DueOut Date 06/10/2017,
Medical Behavior Evaluation GREEN
Medical Summary DVM Intake Exam Estimated age: 2-3 years based on dentition Microchip noted on Intake? Scanned neg History : Found in a basement, hasn’t moved or eaten in a few days. Vomited in the carrier on the way over here. Subjective: Alert, looks around, moves a bit, allows all handling Objective BCS 3/9, MMs pale pink. Temp 96. Moderate dehydration. EENT: Eyes clear, mild brown discharge AU, no nasal discharge noted Oral Exam: Clean teeth, mild gingivitis PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Severely distended, soft and non painful, no masses palpated U/G: Mild purulent vaginal discharge MSI: Ambulatory x 4, skin covered in vomit. No masses noted. CNS: Mentation appropriate – no signs of neurologic abnormalities Lateral abdominal radiograph: Large fluid/soft tissue-filled mass taking up the entire abdomen. Stomach has some food and gas inside it. Some fecal material in the colon. No other organs visible due to soft tissue/fluid opacity. Assessment: Open pyometra highly likely Plan: 1. Placed LVC and started IV LRS 20 ml/hr 2. Ampicillin 250 mg/ml 0.5 ml IV q8 hours x3 days 3. Baytril 22.7 mg/ml 0.8 ml IM q24 x2 days 4. Simbadol 0.5 ml SQ SID x4 days 5. Plan for OVH tomorrow Prognosis: Good with treatment; grave without treatment SURGERY: Okay for surgery 1088
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