AKIL – 31659
Safe - 6-22-2018 Brooklyn
SAFE 6/22/18 Super Friendly Big Kitty AKIL WITH WOUND/ABSCESS Needs Follow Up Care at BACC! Akil was brought to the center as a stray. The clients stated that he used to live inside two buildings and they brought it because he had a wound on the left side of his face.
Brooklyn Center
Akil 31659 – 5 yr. neutered brown tabby/white cat, stray:
Owner profile / Intake info:
Basic Information:
Akil was brought to the center as a stray. The clients stated that he used to live inside two buildings and they brought it because he had a wound on the left side of his face.
Behavior Notes:
Behavior during intake: Akil allowed for all handling.
Behavior:
ENRICHMENT NOTES:
06/19/18
Lying down in his litter box, and turns his head slowly to make eye contact. He sniffs my hand, gives head butts, then shifts his body weight and rolls around. Timid initially, but opens up with attention.
Medical:
Medical History Report
2336 Linden Boulevard
Brooklyn NY 11208
212-788-4000
Animal ID
Name
Type
Mixed
Color(1)
Color(2)
Gender
31659
Akil
Cat
Yes
Brown Tabby
White
Male
Spayed / Neutered
Age
Primary Microchip #
Rabies Tag
Weight
Spay / Neuter Due Date
Temperature
Yes
5 Years (approx)
985113001791392
15 lbs 2.4 oz
Veterinary Clinic Software Record #:
Weight: 15 lbs 2.4 oz
Date of Weighing: 6/18/2018
Date Spayed / Neutered:
Schedule Surgery Date:
Stitches Removal Date:
Clinic Name:
Previously Spayed / Neutered: Yes
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
6/18/2018
Gabapentin (100mg Capsule)
6/18/2018
Rabies
6/18/2018
Re-weigh
6/18/2018
Microchip Implantation
6/18/2018
Internal Parasite Treatment – Pyrantel
6/18/2018
Fvr-Cp 1 Of 2
6/18/2018
Flea/Tick Treatment – Paradefense
6/18/2018
FeLV/FIV Snap
Negative
Vet Treatments Due
Date Due
Vet Treatment Type
7/2/2018
Fvr-Cp 1 Of 2
7/2/2018
Internal Parasite Treatment – Pyrantel
7/2/2018
Re-weigh
7/18/2018
Flea/Tick Treatment – Paradefense
6/18/2019
Rabies
Medications
Medication
Amount Dispensed
Frequency
Date From
Date To
Doses Administered
Vet Name
Reason
Notes
Amoxicillin/Clavulanic Acid Drops 62.5 mg/ml
30 ml
1.5ml po, 2 times every 1 day(s)
19-Jun-2018
After 20 occurrences
0
VET-P 991027
1.5ml po
Gabapentin Capsule 100 mg
14 tablets
1 capsule, 2 times every 1 day(s)
19-Jun-2018
26-Jun-2018
0
VET 991524
Give one capsule by mouth twice a day
Drug Usage
No drugs administered to this animal.
Vet Consultations
Date
Reasons
Vet Notes
Vet
Date Resolved
19-Jun-2018
Progress Exam
Vet Notes: 12:37 PM
H: Noted to have draining tract under left eye. Started on Clavamox. Plan to reassess today.
S: QAR to BARH. NI in food. Sitting in litter box, so unable to assess eliminations. Nervous, but allowed handling.
CRT: <2s. Gums: pink, moist
Eyes: Grossly appropriate OU.
Ears: Unremarkable AU.
Nasal Cavity: No nasal discharge.
Oral Cavity: Mild dental tartar
PLN: WNL
Heart: No murmurs or arrhythmias. Pulses strong and synchronous.
Lungs: Eupneic, lungs clear. No crackles or wheezes bilaterally.
Abd: Soft, non-painful. No palpable masses. No organomegaly appreciated.
U/G: Neutered male. No discharge.
Musculoskeletal: Ambulatory x 4 with no appreciable lameness.
BCS = 8/9
Integument: ~1-2mm open wound noted immediately ventral to OS- mild serosanguinous discharge,minimal swelling and erythema
Neuro: Appropriate mentation. Full neurologic exam not performed.
Rectal: Not performed. Externally normal.
Assessment:
1) Wound/lesion- r/o secondary to dental disease/abscess vs trauma vs less likely neoplasia
Prognosis: good
Plan: Cleaned area with chlorhexidine and saline- continue to monitor area daily
Continue 1.5ml clavamox drop bid x 10d
Started Gabapentin 20mg/kg PO BID x 7 days for stress/anxiety- if appetite not improved, than further treatment may be needed
VET 991524
18-Jun-2018
DVM Intake
Vet Notes: 4:58 PM
[DVM Intake]
DVM Intake Exam
Estimated age:5-8y
Microchip noted on Intake?n
Microchip Number (If Applicable):
History :stray
Subjective:draining tract under left eye, consistent with tooth root abscess
Observed Behavior -allows full exam
Evidence of Cruelty seen -n
Evidence of Trauma seen -n
Objective
T =
P =220
R =wnl
BCS 7/9
EENT: Eyes clear, ears clean, no nasal or ocular discharge noted
Oral Exam:no obvious dental disease but tooth root abscess suspected
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G:neutered
MSI: Ambulatory x 4, skin free of parasites, no masses noted, matted fur on back
CNS: Mentation appropriate – no signs of neurologic abnormalities
Assessment: draining tract/tooth root abscess
Prognosis:good
Plan:1.5ml clavamox drop bid x 10d
dental may be needed
warm compresses bid
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View all entries in: Safe Cats 2018-06