RANDY – A1109154
Gone - 4-18-2017 Brooklyn
GONE 4/18/17 Randy was found lying on side of road – approx 14 yrs old – needs full medical eval – cannot stand – may have trauma – needs further tests.
RANDY – A1109154
SPAYED FEMALE, GRAY TABBY / WHITE, DOMESTIC SH MIX,14 yrs
STRAY – STRAY WAIT, HOLD RELEASED Reason STRAY
Intake condition UNSPECIFIE Intake Date 04/17/2017, From NY 11691, DueOut Date 04/20/2017,
Medical Behavior Evaluation BLUE
Medical Summary 04/17/17 DVM exam. History – Stray cat found lying on the side of the road, cause of injury unknown. Microchip scan negative Age est 14 yrs. Observed behavior – Recumbent on arrival but alert and aware, meows when touched, Did not struggle when lifted. Allowed all handling. Due to current status, unable to fully assess behavior. Evidence of cruelty – No. Evidnece of trauma – No. O: QAR. mm=pink, tacky, CRT<2 s. HR=180, RR=40. BCS=6/9. ORAL: Majority of teeth missing, has several mandibular incisors. EENT: Iris atrophy OU. Mild chemosis and serous ocular discharge. Left ear tipped. Ears mildly dirty AU. No nasal discharge, no sneezing or congestion. H/L: Lungs clear, no dyspnea but mild tachypnea. Lung sounds audible all fields. No murmurs/arrhythmias. ABD: Soft, non-painful. Np palpable masses/organomegaly. UG: Female, spayed. INTEG: Full haircoat, mild flea dirt. No masses or skin lesions, no wounds found. Toenails and pads WNL. Mod decreased skin turgor. MS/NEURO: Able to move head. Unable to stand or walk even when assisted. Collapses with hopping and wheelbarrowing all 4 limbs. Has voluntary movement of all 4 limbs, pos. withdrawal and nociception. All feet are warm, nailbeds pink. No palpable fractures or luxations, no pain on palpation of body or limbs. A: Geriatric spayed female cat, age est 14 yrs. Mild conjunctivitis. Dehydration 5-7%. Able to move limbs but unable to support weight or walk – Tetraparesis. DDx: Trauma with spinal injury, spinal or CNS neoplasia, metabolic disease, toxin exposure, infectious disease, other. P: Whole body lat/VD radiographs: No fractures evident, no obvious spinal luxation or narrowed disc spaces. Increased bronchointerstital pattern in lungs, mild cardiomegaly, mild renal calcification. No mass lesions or fluid evident. Assessment of rads – Findings rule out major trauma as cause of cat’s condition. TX: 100 ml LRS SQ administered. Continue q 24 hours x 3 days. Applied Erythromycin ointment OU. Continue BID x 7 days. House in medical. Recheck tomorrow and perform additional diagnostics including blood tests. Guarded prognosis pending other test results, changes in clinical status. Rec. EHR if worsens.
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