LILY – A1123683
Safe - 9-1-2017 Brooklyn Rescue: AnimalKind Please honor your pledges: http://animalkindny.org/makeadonation/
SAFE 9/1/17 Skinny Gray Kitty With Severe Dehydration – LILY – NEEDS YOU NOW! If the ACC staff does not see significant improvement by the end of day they recommend EHR.
Brooklyn Center
Lily A1123683 – 1 yr. female gray cat, stray:
8/30:
Re-exam dehydration and neurological disease
History : Intake 8/29: stray found on the sidewalk outside laterally recumbent
Subjective: QAR but responsive unlike yesterday. Sitting sternally. ~5% dehydrated. No c/s/v/d noted. Ate eagerly when food held to her face.
Objective
P = wnl R = eupneic BCS 2/9
EENT: Eyes clear, ears clean, no nasal discharge noted, abrasion on top of nose
Oral Exam: clean adult dentition, no oral ulcers
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic
ABD: Non painful, no masses palpated
U/G: FI, no vulvar d/c, no MGTs
MSI: Ambulatory x4, skin free of parasites, no masses noted, emaciated, cachexia
CNS: Mentally appropriate and responsive. PLR normal OU direct and indirect. CN improved-has facial sensation but still unable to close eyes completely (had lube applied yesterday and this morning). Nystagmus has resolved. No ventroflexion noted this morning. Normal posture. Seems overall weak but able to walk around cage. Pupils are normal size and equal.
Assessment:
Obtunded-resolved
Severely dehydrated-improved
Emaciated
Neuro signs-see above-localized to central nervous system specifically intracranial r/o trauma vs infectious vs inflamm vs vascular vs other-improved
Leukocytosis with neutrophilia and suspect bands
Anemia
Elevated ALT
Plan: Continue to monitor while at BACC
Recheck daily
LRS 175ml/kg/day
Temperature-100.3 F
Remove heat support-she was sitting in litter box avoiding heat support anyway
Add eye lube BID x7d
8/29
Panleukopenia snap-negative
CT-negative
CBC-leukocytosis 27.7 (2.87-17.02) with neutrophilia 23.31 (1.48-10.29) and suspect bands; anemia 22.7% (30.2-52.3)
Chem-Elevated ALT 281 (12-130)
T4-wnl
Prognosis: fair
SURGERY: temporary waiver for surgery due to illness
8/29:
Re-exam dehydration and neurological disease
History : Intake 8/29: stray found on the sidewalk outside laterally recumbent
Subjective: QAR but responsive unlike yesterday. Sitting sternally. ~5% dehydrated. No c/s/v/d noted. Ate eagerly when food held to her face.
Objective
P = wnl R = eupneic BCS 2/9
EENT: Eyes clear, ears clean, no nasal discharge noted, abrasion on top of nose
Oral Exam: clean adult dentition, no oral ulcers
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic
ABD: Non painful, no masses palpated
U/G: FI, no vulvar d/c, no MGTs
MSI: Ambulatory x4, skin free of parasites, no masses noted, emaciated, cachexia
CNS: Mentally appropriate and responsive. PLR normal OU direct and indirect. CN improved-has facial sensation but still unable to close eyes completely (had lube applied yesterday and this morning). Nystagmus has resolved. No ventroflexion noted this morning. Normal posture. Seems overall weak but able to walk around cage. Pupils are normal size and equal.
Assessment:
Obtunded-resolved
Severely dehydrated-improved
Emaciated
Neuro signs-see above-localized to central nervous system specifically intracranial r/o trauma vs infectious vs inflamm vs vascular vs other-improved
Leukocytosis with neutrophilia and suspect bands
Anemia
Elevated ALT
Plan: Continue to monitor while at BACC
Recheck daily
LRS 175ml/kg/day
Temperature-100.3 F
Remove heat support-she was sitting in litter box avoiding heat support anyway
Add eye lube BID x7d
8/29
Panleukopenia snap-negative
CT-negative
CBC-leukocytosis 27.7 (2.87-17.02) with neutrophilia 23.31 (1.48-10.29) and suspect bands; anemia 22.7% (30.2-52.3)
Chem-Elevated ALT 281 (12-130)
T4-wnl
Prognosis: guarded
SURGERY: temporary waiver for surgery due to illness
DVM Intake Exam
Estimated age: ~10months-1 year
Microchip noted on Intake? negative
History : stray found on the sidewalk outside laterally recumbent
Subjective: QAR, obtunded, ~7% dehydrated (prolonged skin tent, dry gums, sunken eyes)
Observed Behavior – vocalizing and entending limbs trying to get away but difficult to assess behavior due to obtundation
Evidence of Cruelty seen – no
Evidence of Trauma seen – no
Objective
P = wnl R = eupneic BCS 2/9
EENT: Eyes clear, ears clean, no nasal discharge noted, abrasion on top of nose
Oral Exam: clean adult dentition, no oral ulcers
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic
ABD: Non painful, no masses palpated
U/G: FI, no vulvar d/c, no MGTs
MSI: Non-ambulatory. No fractures or other injuries palpated, skin free of parasites, no masses noted, wet hair coat, emaciated, cachexia
CNS: obtunded, vertical nystagmus. Every few minutes will ventroflex neck and tense up entire body. Vocalizing a lot but not entirely aware. Withdrawal reflex in al 4 limbs but difficult to assess deep pain. CN 7 deficits (decreased facial sensation, unable to fully close eyes). Decreased PLRs bilaterally direct and indirect. Mydriatic pupils. Has occasional torticollis but not to a specific direction.
Assessment:
Obtunded
Severely dehydrated
Emaciated
Neuro signs-see above-localized to central nervous system specifically intracranial r/o trauma vs infectious vs inflamm vs vascular vs other
Leukocytosis with neutrophilia and suspect bands
Anemia
Elevated ALT
Plan: Continue to monitor while at BACC
Recheck daily
Place IVC
LRS 20ml/kg bolus then start on 175ml/kg/day
Heat support
Temp-92.1 F
Panleukopenia snap-negative
CT-negative
CBC-leukocytosis 27.7 (2.87-17.02) with neutrophilia 23.31 (1.48-10.29) and suspect bands; anemia 22.7% (30.2-52.3)
Chem-Elevated ALT 281 (12-130)
T4
If no significant improvement by the end of day rec EHR
Prognosis: guarded
SURGERY: temporary waiver for surgery due to illness
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