PSYCHO aka SANDY – A1108944
Safe - 4-16-2017 Brooklyn
SAFE 4/16/17 — 10 year old Sandy fell out of a dumpster as it was being picked up. He is friendly and already neutered. Sandy is emaciated, dehydrated and seems disoriented – falls over and has some mild tremors – needs full medical eval to determine if neuro or other. He is eating well and needs immediate rescue!
PSYCHO aka SANDY – A1108944
NEUTERED MALE, GRAY, DOMESTIC SH MIX,10 yrs
STRAY – EVALUATE, NO HOLD Reason STRAY
Intake condition INJ SEVERE Intake Date 04/15/2017, From NY 11237, DueOut Date 04/18/2017,
Medical Behavior Evaluation GREEN
Medical Summary 04/15/17 DVM Intake Exam Estimated age: ~10yrs, neutered Microchip noted on Intake? No History : Stray, reportedly fell out of dumpster as it was being picked up Subjective: Observed Behavior – QAR, ~8% dehydrated. Allows all handling. Active. Eating well Evidence of Cruelty seen – No Evidence of Trauma seen – No Objective P = 212bpm R = wnl BCS 2/9 EENT: Dilated pupils, early nuclear sclerosis, Slow PLR, positive menace, ears clean, no nasal discharge noted Oral Exam: Moderate dental tartar and wear, no oral ulcers, mm light pink PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated, kidneys and bladder wnl, empty stomach and bowel loops U/G: Neutered male MSI: Ambulatory x 4, skin free of parasites, no masses noted, dull hair coat, emaciated, no palpable fractures or obvious injuries CNS: Appears disoriented, ataxic, falls over when walking, possible mild intention tremors, Assessment: Geriatric, emaciated, neurologic, dehydrated — R/O cerebellar hypoplasia vs other primary neurologic disease vs neoplasia vs other Plan: Placed IVC, rec 12ml/hr, CBC/chem pending Prognosis: Fair/guarded CBC results wnl WBC 11.04 LYM 3.58 MONO 0.24 NEU 7.07 EOS 0.13 (mildly decreased) BASO 0.02 HCT 24% RBC 7.4 HGB 11.7 RETIC 9.6 %RETIC 0.1% PLT 186 CHEM ALB 4.4 (High 2.3-3.9) ALKP 145 (High 14-111) ALT 399 (High 12-130) BUN 20 CA 10.7 CHOL 124 CREA 1.1 GGT 1 GLOB 3.2 GLU 120 PHOS 3.2 TBIL 0.4 TP 7.6 ALB/GLOB 1.4 BUN/CREA 18 TT4 1.9
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