MAXIMILLION – 31926
Safe - 6-30-2018 Brooklyn Rescue: AnimalKind Please honor your pledges: http://animalkindny.org/donate-index-impact
SAFE 6/30/18 **FIV POSITIVE** MAXIMILLION needs your help today! He was brought in with an abscess on his left front leg and a swollen foot. He needs further medical eval and follow up care. Please offer to foster him so he can get the care he needs.
BROOKLYN CENTER
***FIV POSITIVE***
Maximillion 31926
Location: Brooklyn
Intake Date: 6/21/18
Intake Type: Stray
Medical Behavior: Blue
Sex: Male
Age: 6 years
Original Location: 11208
31926
Maximillion
Cat
Yes
Black
White
Male
Spayed / Neutered
Age
Primary Microchip #
Rabies Tag
Weight
Spay / Neuter Due Date
Temperature
No
6 Years (approx)
8 lbs 6.08 oz
Veterinary Clinic Software Record #:
Weight: 8 lbs 6.08 oz
Date of Weighing: 6/21/2018
Date Spayed / Neutered:
Schedule Surgery Date:
Stitches Removal Date:
Clinic Name:
Previously Spayed / Neutered: No
General Vet Notes:
Previous Medical Details:
Known Allergies or Medical Conditions:
Feeding Requirements:
Indemnities/Waivers:
Medical Notes
Notes
Date
No Medical Notes Stored
Vet Treatments
Date Administered
Vet Treatment Type
Treatment Result
Administered by External Vet
6/21/2018
Re-weigh
6/21/2018
Microchip Implantation
6/21/2018
Rabies
6/21/2018
Fvr-Cp 1 Of 2
6/21/2018
Flea/Tick Treatment – Paradefense
6/21/2018
FeLV/FIV Snap
Positive for FIV
Vet Treatments Due
Date Due
Vet Treatment Type
7/5/2018
Fvr-Cp 1 Of 2
7/5/2018
Internal Parasite Treatment – Pyrantel
7/5/2018
Re-weigh
7/21/2018
Flea/Tick Treatment – Paradefense
6/21/2019
Rabies
Medications
Medication
Amount Dispensed
Frequency
Date From
Date To
Doses Administered
Vet Name
Reason
Notes
Simbadol 1.8mg/ml
2.5 ml
0.5 mL SQ SQ every 1 day(s)
21-Jun-2018
25-Jun-2018
4
VET-P
Give 0.5 mL SQ SID until 6/25/18
Amoxicillin/Clavulanic Acid Drops 62.5 mg/ml
14 ml
1 mL PO, 2 times every 1 day(s)
21-Jun-2018
27-Jun-2018
5
VET-P
Give 1 mL PO BID until 6/27/18
Fluids – LRS SQ
300 ml
100 mL SQ SQ every 1 day(s)
21-Jun-2018
23-Jun-2018
3
VET-P
Give 100 mL SQ until 6/23/18
Robenacoxib INJ 20 mg/ ML
1.2 ml
0.4ml SQ every 1 day(s)
22-Jun-2018
24-Jun-2018
3
VET
Give 0.4ml SQ once a day
Enrofloxacin INJ 100 mg/ML
1.4 ml
0.2ml IM every 1 day(s)
22-Jun-2018
29-Jun-2018
3
Give 0.2ml IM once a day
Fluids – LRS SQ
0 ml
150 SQ every 1 day(s)
23-Jun-2018
28-Jun-2018
1
VET
LRS 150ml SQ SID
Fortiflora (probiotic supplement)
0
1 every 1 day(s)
24-Jun-2018
29-Jun-2018
0
VET
Give 1 packet in food SID
Drug Usage
No drugs administered to this animal.
Vet Consultations
Date
Reasons
Vet Notes
Vet
Date Resolved
24-Jun-2018
Progress Exam
Vet Notes: 12:42 PM
Progress exam
History : stray intake 6/21, reported to have wounds. Sedated for wound treatment-had abscesses at right carpus, left forelimb proximal to the wound on lateral humerus. Started on baytril, clavamox, SQ LRS, and simbadol.
Radiographs-Right carpal bones appear to have osteolysis, no obvious fractures seen; mild swelling around right carpus, Large amount of soft tissue swelling at left shoulder region, Thoracic cavity appears WNL, Pelvis and abdomen WNL
Chemistry-mild hyperglobulinemia 6.6g/dL (high – 2.8 – 5.1), mild hyperglycemia 187mg/dL (high – 74 – 159), elevated TBili 3.6mg/dL (high 0 – 0.9)
6/22-started on onsior.
CBC: Mildly regenerative, moderate anemia (Hct 18.6%, Retic 63K); moderate leukocytosis (37.13K), neutrophilia (29.4K), monocytosis (1.6), basophilia (0.33)
Chemistry: Tbili 3.8
Subjective: QARH. Good appetite. Has diarrhea in the cage. Normal U. No csv. Will have wound treatment and neuter tomorrow.
Objective
P = wnl
R = wnl
BCS 4/9
EENT: Eyes clear, mild brown waxy debris AU, no nasal or ocular discharge noted
Oral Exam: mild to moderate dental disease
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic
ABD: Non painful, no masses palpated
U/G: MI, 2 testicles descended
MSI: amnbulatory x4, limited gait assessment-will flee. ~2xm full thickness wound on left lateral elbow with serous d/c and muscle exposed. Right carpus is swollen and painful to the touch with no draining wound. Dirty haircoat. No ectoparasites or masses noted
CNS: Mentation appropriate – no signs of neurologic abnormalities
Assessment:
1) FIV+
2) Abscess of left arm
3) Swelling on right carpus (likely an abscess) with possible carpal osteolysis noted on rads
4) Geriatric
5) Hyperbilirubinemia/icterus- Given pale MM and no elevations in other liver enzymes, a pre-hepatic process (ie hemolysis) would be the top differential Differentials for intravascular hemolysis would be infectious (mycoplasma haemofelis) vs IMHA (primary v secondary to neoplasia, less likely new medication or vaccines). However, cannot r/o primary cholestatic disease such as mucocele, cholecystitis, choleliths, biliary neoplasia, etc.
6) Anemia, mildly regenerative- Top differentials would be secondary to hemorrhage vs infectious process, though more likely infectious given the hyperbilirubinemia. IMHA (primary v secondary) can also not be entirely ruled out. BEcause of the mild regenerative process, non-regenerative causes (anemia of chronic disease/inflamamtion, neoplasia) can also not be entirely ruled out.
Prognosis: Fair
Plan:
CTM while at BACC
Continue simbadol until 6/25
Continue clavamox until 6/27
Continue SQ LRS until 6/28
Continue baytil until 6/29
Start fortiflora 1 pack in food SID x5d until 6/29
Last day of onsior
Will have wound treatment and neuter tomorrow if CBC/Chem is stable
Will possibly need amputation of RFL
VET
23-Jun-2018
Progress Exam
Vet Notes: 1:00 PM
Recheck comfort and wounds on front limbs
H: Intake on 6/21, noted to be FIV+, dehydrated, underweight, swollen carpus and abscess on LFL
– Patient was sedated for radiographs, bloodwork (chemistry) and wound clean
Chemistry: Creatinine 0.6mg/dL (low – 0.8-2.4), Globulin 6.6g/dL (high – 2.8 – 5.1), Glucose 187mg/dL (high – 74 – 159), TBili 3.6mg/dL (high 0 – 0.9)
Radiographs: In comparison with the left carpus, the right carpus appears compressed with possible osteolysis of the carpal bones noted
– Started on Clavamox, Baytril, Simbadol, SQ fluids
CBC: Mildly regenerative, moderate anemia (Hct 18.6%, Retic 63K); moderate leukocytosis (37.13K), neutrophilia (29.4K), monocytosis (1.6), basophilia (0.33)
S/O: BAR. ~5-8% dehydration. Excellent appetite, drinking water. Soft stool. Allows handling.
EENT: Eyes clear, no ocular or nasal discharge, moderate dental staining, pale mm with mild icterus
HL: No sneezing, normal RR/RE
INTEG: Dirty hair coat; ~1-2cm open wound at lateral left front limb proximal to elbow with mild purulent discharge; no swelling or discharge from left shoulder region where abscess was treated
MS: Ambulatory x 4, moderate swelling at right carpus with crepitus
UG: Male
A:
1) FIV+
2) Abscess, left elbow
3) Suspect compressive fracture/osteolysis of right carpus
4) Hyperbilirubinemia/icterus- Given pale MM and no elevations in other liver enzymes, a pre-hepatic process (ie hemolysis) would be the top differential (especially given #5). Differentials for intravascular hemolysis would be infectious (mycoplasma haemofelis) vs IMHA (primary v secondary to neoplasia, less likely new medication or vaccines). However, cannot r/o primary cholestatic disease such as mucocele, cholecystitis, choleliths, biliary neoplasia, etc.
5) Anemia, mildly regenerative- Top differentials would be secondary to hemorrhage (given #2-3) vs infectious process (given #4), though more likely infectious given the hyperbilirubinemia. IMHA (primary v secondary) can also not be entirely ruled out. BEcause of the mild regenerative process, non-regenerative causes (anemia of chronic disease/inflamamtion, neoplasia) can also not be entirely ruled out.
6) Dehydrated
7) Geriactric
Prognosis: Guarded
P: Continue with current treatment and monitoring plan. Extending LRS 150ml SQ q24 x 5 days
VET
22-Jun-2018
22-Jun-2018
22-Jun-2018
Progress Exam
Blood Work Interpretation
Vet Notes: 11:06 AM
H: Intake on 6/21, noted to be FIV+, dehydrated, underweight, swollen carpus and abscess on LFL
– Patient was sedated for radiographs, bloodwork (chemistry) and wound clean
Chemistry: Creatinine 0.6mg/dL (low – 0.8-2.4), Globulin 6.6g/dL (high – 2.8 – 5.1), Glucose 187mg/dL (high – 74 – 159), TBili 3.6mg/dL (high 0 – 0.9)
Radiographs: In comparison with the left carpus, the right carpus appears compressed with possible osteolysis of the carpal bones noted
– Started on Clavamox, Baytril, Simbadol, SQ fluids
S: QAR. ~5% dehydrated. Ate well. Moderate urine in cage. Soft brown stool.
HR 200bpm
RR 16
T 102.7F
CRT: <2s. Gums: pale/icteric, sl tacky
Eyes: Grossly appropriate OU.
Ears: Unremarkable AU.
Nasal Cavity: No nasal discharge.
Oral Cavity: Mild to moderate dental tartar/periodontal disease
PLN: WNL
Heart: No murmurs or arrhythmias.
Lungs: Eupneic, lungs clear. No crackles or wheezes bilaterally.
Abd: Soft, non-painful. No palpable masses. No organomegaly appreciated.
U/G: Intact male, no discharge. No discharge.
Musculoskeletal: Non-ambulatory, prefers to be recumbent. ~1-2cm open wound noted on the lateral aspect of the left elbow, mild purulent discharge. RFL (carpus/antebrachium) moderate to severely swollen with small puncture noted at the dorsal aspect of the carpus. Crepitus felt over right carpus.
BCS = 3/9
Integument: Roughened haircoat
Neuro: Appropriate mentation. Full neurologic exam not performed.
Rectal: Not performed. Externally normal.
CBC: Mildly regenerative, moderate anemia (Hct 18.6%, Retic 63K); moderate leukocytosis (37.13K), neutrophilia (29.4K), monocytosis (1.6), basophilia (0.33)
Chemistry: Tbili 3.8
Assessment:
1) FIV+
2) Abscess, left elbow
3) Suspect compressive fracture/osteolysis of right carpus
4) Hyperbilirubinemia/icterus- Given pale MM and no elevations in other liver enzymes, a pre-hepatic process (ie hemolysis) would be the top differential (especially given #5). Differentials for intravascular hemolysis would be infectious (mycoplasma haemofelis) vs IMHA (primary v secondary to neoplasia, less likely new medication or vaccines). However, cannot r/o primary cholestatic disease such as mucocele, cholecystitis, choleliths, biliary neoplasia, etc.
5) Anemia, mildly regenerative- Top differentials would be secondary to hemorrhage (given #2-3) vs infectious process (given #4), though more likely infectious given the hyperbilirubinemia. IMHA (primary v secondary) can also not be entirely ruled out. BEcause of the mild regenerative process, non-regenerative causes (anemia of chronic disease/inflamamtion, neoplasia) can also not be entirely ruled out.
6) Dehydrated
7) Geriactric
Prognosis: Guarded
Plan:
Continue Simbadol until 6/25
Continue Clavamox until 6/27
Continue 100mls LRS SQ SID until 6/23
Changed Enrofloxacin 5mg/kg to IM SID x 7 days- should also treat mycoplasma if present
Added Onsior 2 mg/kg SQ SID x 3 days
Will attempt to do full bloodwork today (CBC/Chem/T4)
VET
21-Jun-2018
DVM Intake
Blood Work Interpretation
Vet Notes: 6:11 PM
Radiographs
Right carpal bones appear irregular, no obvious fractures seen; mild swelling around right carpus
Large amount of soft tissue swelling at left shoulder region
Thoracic cavity appears WNL
Pelvis and abdomen WNL
Chemistry
Creatinine 0.6mg/dL (low – 0.8-2.4)
Globulin 6.6g/dL (high – 2.8 – 5.1)
Glucose 187mg/dL (high – 74 – 159)
TBili 3.6mg/dL (high 0 – 0.9)
All other results WNL
A: Possible carpal fractures, abscess at left shoulder region
Mild hyperglycemia – R/O stress
Mild hyperglobulinemia – R/O inflammation
Moderately increased Tbili – R/O Liver/gallbladder disease vs infection vs other
FIV+
Dental disease
Dehydration
Underweight
Abscesses/wounds
NOTE: Eating well after procedure
Vet Notes: 4:46 PM
[DVM Intake]
DVM Intake Exam
Estimated age: approx 6 yo
Microchip noted on Intake? neg
Microchip Number (If Applicable):
History : stray, reported to have a draining wound on one of the limbs.
Subjective: BAR. Open draining wound on left lateral humerous, swollen right carpus. P was well behaved during PE, no signs of aggression. Needed to approach slowly with minimal handling. P did not like med handling, started growling, hissing.
Observed Behavior –
Evidence of Cruelty seen – n
Evidence of Trauma seen – n
Objective
T =
P = wnl
R = wnl
BCS 3/9
MM light pink, tacky, slight delay in skin turgor, 7% dehydrated
EENT: Eyes clear, mild debris and wax AU, no nasal or ocular discharge noted
Oral Exam: p resisted thorough oral exam, no obvious lesions/ulcers noted, gingival recession with upper canines.
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic, normal RR/RE
ABD: Non painful, no masses palpated
U/G: MI, 2 testicles
MSI: Open draining circular wound on lateral left humerus, underlying muscle and tissues exposed. Swelling on right carpus, p sensitive to palpation, possible puncture wound on dorsal surface . Did not assess ambulation, p was lying lateral in carrier. Skin free of parasites, no masses noted, dirty hair coat
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal: normal externally
Assessment:
FIV+
open draining wound on left arm — r/o old wound/ruptured abscess
swelling on right carpus — r/o abscess, vs trauma/fracture
dehydration
underweight
intact male
Prognosis: good
Plan:
sedated wound treatment
chem (CBC pending)
rads of front limbs
simbadol 0.5 mL SQ SID x 5 days
clavamox 1 mL PO BID x 7 days
LRS 100 mL SQ x 3 days
monitor in medical
SURGERY:
Temporary waiver due to wounds
ADDENDUM:
Sedated with dexdomitor/butorphanol 0.3/0.07ml IM for diagnostics and wound treatment
Flushed open wound at left humerus with sterile LRS and cleaned with nolvasan
Large fluctuant swelling noted proximal to open wound at left arm – lanced with #15 blade, ~10-15ml of purulent fluid expressed; flushed with sterile LRS and cleaned with nolvasan
Crepitus and swelling at right carpus, FNA produced small amount of purulent discharge
Mild jaundice
No other wounds noted
Adding baytril 100mg/ml – 0.18ml SQ q24 x 5 days
Consider wound debridement and closure for wound on left arm when patient more stable – started waking up from sedation before closure was possible
VET-P
Behavior:
This information is supplied as a guide only based on the history supplied to us and on our observations of the animal in the shelter. Animal Care Centers of NYC, its employees and agents accept no responsibility in the event that the animal behaved differently from its description above nor are any guarantees made in respect of its future behavior.
Animal Behavior Saved At: 24-Jun-2018 15:6:44.000
Animal ID:
31926
Animal Name: Maximillion
Age: 6 Years (approx)
Tag Number:
Breed: Domestic Short Hair
Gender: Male
Spayed / Neutered: No
Behavior Assessment Date:
6/24/2018
KNOWN HISTORY:
Maximillion was brought in as a stray, so there is no information on their behavior history or tendencies in a home environment. He allowed the finder and staff to handle him during intake.
MEDICAL BEHAVIOR:
06/21/18
Subjective: Was well behaved during PE, no signs of aggression. Needed to approach slowly with minimal handling. Did not like med handling, started growling, hissing.
Cage Condition:
Cage is recently cleaned
Reaction to assessor:
Maximillion was lying down by the front, calm and relaxed.
Reaction when softly spoken to:
Maximillion makes eye contact and meows softly.
Reaction to cage door opening:
Maximillion gets up and sniffs around.
Reaction to touch:
Maximillion sniffs the assessor’s hand and slowly shifts away in anticipation. He allows petting with a very slow approach and is tense; his body remains low and he curls his tail around his body, but he allows petting all over and doesn’t display any further reaction.
Reaction to being picked up:
Maximillion remains tense, but is tolerant of this kind of handling.
ACTIVITY LEVEL:
Moderate
VOCAL:
Quiet
CHARACTER TYPE:
Shy
Calm
Curious
BEHAVIOR DETERMINATION:
Experience
Behavior Asilomar
TM – Treatable-Manageable
BEHAVIOR SUMMARY:
Maximillion tolerates attention and petting but may be fearful or stressed in the shelter. He may be a little more independent, and may need time to warm up to his new home. We recommend that this cat go to a home with experienced cat parents.
Other:
06/24/18 Experience
Profile:
This behavior note was written by the previous owner of this pet. Animal Care Centers of NYC provides this as a guide for optimal pet placement.
Please use these notes in conjunction with the information provided by NYCACC.
Animal ID: 31926
Animal Name: Maximillion
Breed: Domestic Short Hair
This animal came from:
Found Stray
If yes, Please elaborate:
Unknown information
Basic Information:
Maximillion is a black and white cat that was found on the street injured and was brought to the ACC as a stray.
Previously lived with:
Unknown information
How is this cat around strangers?
Feline allowed all handling.
How is this cat around children?
Unknown information
How is this cat around other cats?
Unknown information
How is this cat around dogs?
Unknown information
Behavior Notes
Unknown information
Bite history:
Unknown information
Medical Notes
Unknown information
For a New Family to Know
Unknown information
Behavior Notes:
During intake feline allowed the counselor to collar him with no problem.
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View all entries in: Safe Cats 2018-06