SYBIL – 11966
Safe - 11-10-2017 Staten Island
SAFE 11/10/17 SYBIL is a friendly 5 yr old who was brought in as a stray. She is already spayed but has severe anemia and needs more medical evaluation to determine what is wrong. She has hematuria and may have a UTI. Please help this poor girl today!
STATEN ISLAND CENTER
Sybil 11966
Location: Staten Island
Intake Date: 11/7/17
Intake Type: Stray
Medical Behavior: Green
Age: 5 years
Sex: Spayed female
Weight: 5 lbs
DVM Intake Exam
Estimated age: 5 years
Microchip noted on Intake? scan negative
History : stray
Subjective:
Observed Behavior – friendly, QAR
Evidence of Cruelty seen -no
Evidence of Trauma seen -no
Objective
temp= 101.3
BCS 4/9 with dorsal muscle wasting
EENT: Eyes clear, ears clean, no nasal or ocular discharge noted
Oral Exam: mild/moderate dental calc and gingivitis; mm’s pale pink, tacky
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic
ABD: Non painful, no masses palpated
U/G: FS, spay scar seen
MSI: Ambulatory x 4, flea dirt, no masses noted, decreased skin turgor
CNS: Mentation appropriate – no signs of neurologic abnormalities
Assessment
dehydrated
pale mm’s- R/O anemia vs poor perfusion vs other
underweight- R/O dietary vs Gi disease vs renal disease vs other
Prognosis: guarded
Plan:
CBC/chemistry
LRS SQ fluids 75 mls x 2 days
Vet Notes: 5:07 PM
severe anemia (hematocrit= 18.9)- R/O flea anemia vs FIV/FeLV vs FIP vs hemotrophic mycoplasmosis vs trauma vs neoplasia vs other
moderate neutrophilia and monocytosis- R/O infection vs inflammation vs other
moderate hyperglobulinemia- R/O infection vs inflammation vs neoplasia vs other
Urinalysis:
Leuk 500
PRO 500
Gluc NEG
KET NEG
UBG norm
BIL NEG
BLD 250
USG >1.050
hematuria, proteinuria, pyuria- R/O infection vs inflammation vs neoplasia vs other
start doxycycline 26 mg PO SID x 14 days in case of hemotrophic mycoplasmosis
start amoxi/clav 37 mg PO BID x 7 days for possible UTI
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View all entries in: Safe Cats 2017-11