LOGAN – A1121983
Gone - 8-14-2017 Brooklyn
GONE 8/14/17 LOGAN was brought to the shelter in rough shape – she was lethargic and has some wounds and is too weak to stand. Has dental disease.
Needs immediate help.
LOGAN – A1121983
FEMALE, GRAY TABBY / WHITE, DOMESTIC SH MIX,7 yrs
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition ILLNESS Intake Date 08/14/2017, From NY 11208, DueOut Date 08/17/2017,
Medical Behavior Evaluation BLUE
Medical Summary DVM Intake Exam Estimated age: 7-8 years Microchip noted on Intake? negative History : stray Subjective: quiet, not alert, and minimally responsive; ~7-8% dehydrated (prolonged skin tent, dry gums) Observed Behavior -not neurologically appropriate, unable to determine behavior but allowed all medical handling Evidence of Cruelty seen – no Evidence of Trauma seen – no Objective P = wnl R = eupneic BCS 7/9 EENT: Mild mucoid d/c ou, ears clean, no nasal discharge noted Oral Exam: severe dental disease PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic ABD: Non painful, no masses palpated, doughy U/G: F, unknown if spayed MSI: non-ambulatory, skin free of parasites, no masses noted, 2 large patches of thickened skin with hairloss on ventrum, very erythematous and hard CNS: not responsive, absent menace, minimal PLR OU direct and indirect, decreased facial nerve response (no movement when ears, cheek, or lateral canthus probed), head tremors, spins forward on top of head when not retrained. Unable to assess limbs because laterally recumbent and too weak/neurologically inappropriate to stand, decrease dazzle response. Not aware of surroundings Assessment: Neurologically inappropriate-see above-localized to central nervous cranial disorder Wounds on ventrum-r/o burns vs chemical vs other Dental disease High ALP r/o cholestasis vs hyperthyroidism Hyperbilirubinuria r/o pancreatitis vs cholestasis vs liver disease Hypochloremia r/o vomiting vs diarrhea vs other losses Mild leukocytosis with lymphocytosis, monocytosis, neutrophilia Mild eosinopenia Mild anemia Plan: CBC-Mild leukocytosis 21.4 (2.87-17.02), lymphocytosis 8.44 (0.92-6.88), monocytosis 1 (0.05-0.67), neutrophilia 11.92 (1.48-10.29) with bands, eosinopenia 0.03 (0.17-1.57), anemia 27.8% (30.3-52.3) Chemistry-high ALP 451 (14-111), hyperbilirubinemia 2.5 (0-0.9), hypochloremia 109 (112-129) Place IVC Start LRS-give 20ml/kg bolus then start on 100ml/kg/day Diazepam 0.5mg/kg IV Continue to monitor while at BACC If no improvement by the end of today, rec HE Prognosis: guarded SURGERY: temporary waiver for surgery due to illness
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