STITCH – 17484
Safe - 1-6-2018 Staten Island Rescue: Whiskers-a-GoGo Please honor your pledges: https://www.whiskers-agogo.org/donate
SAFE 01/06/18 This girl just came in and appears to have some neurologic issues. Our vet stated she is not sure if this is caused by an ear infection and could be vestibular however Stitch should be assessed further by a private veterinarian. She is eating and has a great appetite.
Staten Island Center
17484 – Stitch – 3 month female – 2.75lbs
Vet Consultations
Date
Reasons
Vet Notes
Vet
Date Resolved
4-Jan-2018
Progress Exam
Vet Notes: 4:00 PM
Subjective:
recheck exam; eating canned food; given a convenia injection on 1/2/18
Objective
BCS 5/9
EENT: OU- slight nystagmus but improved, pupils symmetric, normal palpebral response, inconsistent menace response AS- moderate amount of tan debris, no polyp seen but unable to visualize tympanum; AD- clean, no nasal or ocular discharge noted
Oral Exam: deciduous teeth, limited exam; mm’s pink
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic
ABD: Non painful, no masses palpated
U/G: FI
MSI: Reluctant to ambulate during exam but ataxia appears improved, flea dirt, no masses noted, healthy hair coat
CNS: still has head tilt to left but improved; normal conscious proprioception; alert and appropriate
Assessment
head tilt, nystagmus, ataxia- R/O otitis interna vs polyp vs infectious vs trauma vs other; improving
flea dirt- treated with Revolution on 1/2/18
Plan:
CBC/chemistry
continue to monitor
simbadol 0.15 mls SQ (x)
VET 991385
4-Jan-2018
Blood Work Interpretation
Vet Notes: 3:48 PM
CBC:
slight neutrophilia- R/O infection vs inflammation vs stress vs other
eosinophilia- R/O parasites vs allergies vs other
basophilia
increased platelets
Chemistry:
mild hyperglobulinemia- R/O chronic infection vs inflammation vs other
VET 991385
2-Jan-2018
Spay-Neuter Waiver Documentation
Vet Notes: 3:46 PM
[Spay/Neuter Waiver – Medical Condition]
Your newly adopted pet has been diagnosed with neurologic signs and the staff veterinarians are issuing a permanent waiver from the spay/neuter requirements of the City of NY. Follow up care at your regular veterinarian is recommended to ensure continued treatment. Your veterinarian will advise you if surgical sterilization is appropriate.
2-Jan-2018
DVM Intake
Vet Notes: 3:30 PM
[DVM Intake]
DVM Intake Exam
Estimated age: 3 months
Microchip noted on Intake? scan negative
History : stray
Subjective:
Observed Behavior – hissing, swatting, biting glove
Evidence of Cruelty seen -no
Evidence of Trauma seen – neurologic signs
Objective
BCS 5/9
EENT: OU- horizontal nystagmus, pupils symmetric, normal palpebral response, inconsistent menace response AS- moderate amount of tan debris, unable to perform otoscopic exam; AD- mild debris, no nasal or ocular discharge noted
Oral Exam: deciduous teeth, limited exam; mm’s pink
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic
ABD: Non painful, no masses palpated
U/G: FI
MSI: Appears ataxic, flea dirt, no masses noted, healthy hair coat
CNS: head tilt to the left
Assessment
head tilt, nystagmus, ataxia- R/O otitis interna vs polyp vs infectious vs trauma vs other
flea dirt
Prognosis: fair to guarded
Plan:
gave convenia injection 0.12 mls SQ (x)
applied Revolution
recommend placement for further diagnostics and treatment
SURGERY:
Permanent waiver due to neurologic signs
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View all entries in: Safe Cats 2018-01