GUINEVERE – A1126396
Gone - 9-25-2017 Brooklyn
GONE 9/25/17 **NEEDS FOLLOW UP VET CARE FOR LETHARGY / DEHYDRATION …Our Lady GUINEVERE Is The Sweetest! *** GUINEVERE is a stray who was found abandoned in a carrier. She is dehydrated and lethargic and was not eating well. Needs further medical eval – please help this poor kitty. She is only about a year old.
BROOKLYN CENTER
GUINEVERE – A1126396
FEMALE, WHITE / BRN TABBY, DOMESTIC SH MIX,1 yr
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition ILLNESS Intake Date 09/23/2017, From NY 10304, DueOut Date 09/26/2017,
Medical Behavior Evaluation GREEN
Medical Summary DVM Intake Exam Estimated age: ~1-2 years Microchip noted on Intake? negative History : stray found abandoned in a carrier. Not eager to eat Subjective: QAR and ~6% dehydrated (dry gums, prolonged skin tent) Observed Behavior – was very dumpy but allowed all handling and eagerly came out of carrier Evidence of Cruelty seen – no Evidence of Trauma seen – no Objective T = 100 F P = wnl R = wnl BCS: 5/9 EENT: Eyes clear, ears have mild brown waxy debris, no nasal discharge noted Oral Exam: clean adult dentition, no oral lesions PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic ABD: Non painful, no masses palpated, doughy U/G: FI, no vulvar d/c, no MGTs MSI: Ambulatory x 4, skin free of parasites, no masses noted, haircoat is wet on hindend CNS: mentation appropriate – no signs of neurologic abnormalities Assessment: Dehydrated Lethargic Decreased appetite Plan: CTM while at BACC Recheck tomorrow-keep in medical, consider app stimulant +/- rads tomorrow +/- IVF LRS 100ml SQ SID x3d CBC Chem Prognosis: Fair SURGERY: Temporary waiver due to illness
Weight 7.7
Medical::
09/23/17:
DVM Intake Exam
Estimated age: ~1-2 years
Microchip noted on Intake? negative
History : stray found abandoned in a carrier. Not eager to eat
Subjective: QAR and ~6% dehydrated (dry gums, prolonged skin tent)
Observed Behavior – was very dumpy but allowed all handling and eagerly came out of carrier
Evidence of Cruelty seen – no
Evidence of Trauma seen – no
Objective
T = 100 F P = wnl R = wnl BCS: 5/9
EENT: Eyes clear, ears have mild brown waxy debris, no nasal discharge noted
Oral Exam: clean adult dentition, no oral lesions
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic
ABD: Non painful, no masses palpated, doughy
U/G: FI, no vulvar d/c, no MGTs
MSI: Ambulatory x 4, skin free of parasites, no masses noted, haircoat is wet on hindend
CNS: mentation appropriate – no signs of neurologic abnormalities
Assessment:
Dehydrated
Lethargic
Decreased appetite
Plan:
CTM while at BACC
Recheck tomorrow-keep in medical, consider app stimulant +/- rads tomorrow +/- IVF
LRS 100ml SQ SID x3d
CBC
Chem
Prognosis: Fair
SURGERY: Temporary waiver due to illness
09/24/17:
Re-exam: dehydration and lethargic
History: stray found abandoned in a carrier. Not eager to eat on intake. Started on LRS SQ
Subjective: QAR and ~6% dehydrated (dry gums, prolonged skin tent). Has not eaten any of her food.
Objective
P = wnl R = wnl BCS: 5/9
EENT: Eyes clear, ears have mild brown waxy debris, no nasal discharge noted
Oral Exam: clean adult dentition, no oral lesions
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic
ABD: Non painful, no masses palpated, doughy
U/G: FI, no vulvar d/c, no MGTs
MSI: Ambulatory x 4, skin free of parasites, no masses noted, haircoat has dried yellow/brown material on hindend
CNS: mentation appropriate – no signs of neurologic abnormalities
Assessment:
Dehydrated
Lethargic
Decreased appetite
Severe leukocytosis with severe neutrophilia, suspect bands, severe lymphocytosis, and severe monocytosis
Severe basophilia
Eosinophilia
Azotemia
Elevated GGT
Hyperglobulinemia
Hyperbilirubinemia
Hyponatremia
Hypochloridemia
Plan:
CTM while at BACC
Recheck tomorrow-keep in medical, consider app stimulant
LRS 100ml SQ SID x3d
CBC (from yesterday-seen this morning)-Severe leukocytosis 117.85 (2.8-17.02) with severe neutropenia 1.16 (1.48-10.29), suspect bands, severe lymphocytosis 85.03 (0.92-6.88), and severe monocytosis 28.83 (0.05-0.67), severe basophilia 1.05 (0.01-0.26), eosinophilia 1.78 (0.17-1.57)
Chem (from yesterday-seen this morning)-Low ALP <10 (14-111), azotemia BUN 51 (16-36) and creatinine is too high to read, high GGT 55 (0-4), hyperglobulinemia 5.6 (2.8-5.1), hyperbilirubinemia 1.5 (0-0.9)
2 view AXR-decreased abdominal detail with possible wispy detail in abdomen r/o free fluid vs FIP
Place IVC
Start IVF LRS @ 90ml/kg/day
Start baytril 5mg/kg IV SID x10d
Cerenia 1mg/kg IV SID x3d
Mirtazapine 15mg: 1/4 tablet PO
Prognosis: Fair
09/25/17:
Re-exam: dehydration and lethargic
History : stray found abandoned in a carrier. Not eager to eat on intake. Started on LRS SQ. On 9/24 a IVC was placed and stated on IVF throughout the day. She was taken off fluids overnight.
CBC (from yesterday-9/23)-Severe leukocytosis 117.85 (2.8-17.02) with severe neutropenia 1.16 (1.48-10.29), suspect bands, severe lymphocytosis 85.03 (0.92-6.88), and severe monocytosis 28.83 (0.05-0.67), severe basophilia 1.05 (0.01-0.26), eosinophilia 1.78 (0.17-1.57)
Chem (from yesterday-seen this morning)-Low ALP <10
Subjective: QAR and ~6% dehydrated (dry gums, prolonged skin tent). Has not eaten any of her food. Is perkier than yesterday but still dehydrated and lethargic and not eating.
Objective
P = wnl R = wnl BCS: 5/9
EENT: Eyes clear, ears have mild brown waxy debris, no nasal discharge noted
Oral Exam: clean adult dentition, no oral lesions, dry gums
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic
ABD: Non painful, no masses palpated, doughy
U/G: FI, no vulvar d/c, no MGTs
MSI: Ambulatory x 4, skin free of parasites, no masses noted, haircoat has dried yellow/brown material on hindend
CNS: mentation appropriate – no signs of neurologic abnormalities
Assessment:
Dehydrated
Lethargic
Decreased appetite
Severe leukocytosis with severe neutrophilia, suspect bands, severe lymphocytosis, and severe monocytosis
Severe basophilia
Eosinophilia
Azotemia
Elevated GGT
Hyperglobulinemia
Hyperbilirubinemia
Hyponatremia
Hypochloridemia
Plan:
CTM while at BACC
Recheck tomorrow-keep in medical, consider app stimulant tomorrow if still not eating
LRS 20ml/kg bolus then 90ml/kg/day
baytril 5mg/kg IV SID
Cerenia 1mg/kg IV SID
Prognosis: Fair
Profile::
09/23/17:
Guinevere came out of the carrier with no problems. She was rubbing on the counselor and enjoyed being pet. She allowed the counselor to colar her and take her picture with no problems.
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