GOLDIE – A1120493
Gone - 8-1-2017 Manhattan
GONE 8/1/17 — 12 year old Goldie was brought in as a stray – is lethargic, dehydrated, mildly anemic and has a high white cell count – needs immediate rescue – shelter is recommending euth.
GOLDIE – A1120493
NEUTERED MALE, ORANGE / WHITE, DOMESTIC MH MIX,12 yrs
STRAY – STRAYAVAI, NO HOLD Reason STRAY
Intake condition GERIATRIC Intake Date 08/01/2017, From NY 10030, DueOut Date 08/04/2017,
Medical Behavior Evaluation BLUE
Medical Summary DVM Intake Exam Estimated age: 12-14 years Microchip noted on Intake? neg History : found as a stray Subjective: QDR, severe dehydration Observed Behavior – vocal during blood draw and growled when putting back in carrier but allows handling; very lethargic Evidence of Cruelty seen – none Evidence of Trauma seen – none Objective BCS 3/9 EENT: OU-pupils dilated, age related changes to iris; immature cataracts; corneas appear slightly dull with mild mucoid discharge no nasal discharge, eyes clear Oral Exam: mm pale, tacky; severe tartar/staining PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: nonpainful, doughy; intestines feel focally thickened U/G: neutered MSI: ambulatory x 4 but resistant to move around significant dehydration severe muscle wasting unthrifty coat CNS: mentation appropriate – no signs of neurologic abnormalities Rectal: not performed Assessment Geriatric Pale mm Dehydrated Muscle wasting Plan CBC/chem/T4-mild anemia in the face of severe dehydration so likely significantly worse, nonregenerative; severe neutrophilia, mild monocytosis; mild to mod BUN elevation; overall non specific signs; due to severe muscle wasting and blood work changes, there is significant concern of aggressive process such as neoplasia Based on tempermanet, severe dehydration and blood work changes, rec’d EHR Prognosis: poor SURGERY: neutered
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