AVERY – 18163

Brooklyn Center

*BLIND*

18163 –  Avery
Cat Yes
Orange Tabby White

Male

Spayed / Neutered
Age
Primary Microchip #
Rabies Tag
Weight
Spay / Neuter Due Date
Temperature

Yes
9 Years

7 lbs 2.56 oz

Veterinary Clinic Software Record #:
Weight:   7 lbs 2.56 oz

Incoming Agency: Animal Care Centers of NYC
Date of Weighing:   1/12/2018

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
1/12/2018
FeLV/FIV Snap
Negative

1/13/2018
Fvr-Cp Series

1/13/2018
Rabies

1/13/2018
Microchip Implantation

1/13/2018
Internal Parasite Treatment – Pyrantel

1/13/2018
Flea/Tick Application – Topical

Vet Treatments Due
Date Due
Vet Treatment Type
1/27/2018
Fvr-Cp Series
1/27/2018
Internal Parasite Treatment – Pyrantel
2/13/2018
Flea/Tick Application – Topical
1/13/2019
Rabies

Medications
Medication
Amount Dispensed
Frequency
Date From
Date To
Vet Name
Reason
Notes
NeoPolyBAC w/HC Ophthalmic Ointment
6 tube
BID
1/12/2018
1/15/2018
VET-P 991444

Apply 1/4 inch to left eye 2 x daily
Fluids – LRS SQ
0 ml
SID
1/13/2018
1/15/2018

LRS 100ml SQ
Doxycycline Suspension 50 Mg/ml
0.7 ml
SID
1/14/2018
1/24/2018

Give 0.7ml PO SID
Mirtazipine 15 mg
0.25 tablets
Once
1/14/2018
1/14/2018

Give 1/4 tab PO once

Drug Usage
No drugs administered to this animal.

Vet Consultations
Date
Reasons
Vet Notes
Vet
Date Resolved
14-Jan-2018
Progress Exam
Blood Work Interpretation
Vet Notes: 8:58 AM

Progress exam

History : stray intake 1/12-hypothermia, blind, possible neoplasia. Given SQ LRS, heat support, and simbadol. Fluorescein stain negative OU.
1/13:
CBC: leukocytosis 27.29 (2.87 – 17.02 K/µL) with neutrophilia 25.82 (1.48 – 10.29 K/µL), thrombocytopenia likely from clumping
Chem: hyperglobulinemia 5.6 (2.8 – 5.1 g/dL), mild elevation in ALT 138 (12 – 130 U/L)
T4: wnl (1)

Subjective: QARH. Minimally responsive. No interest in food. No csvd but is audibly congested. No bm or u in litter box.

Objective
T =
P = wnl
R = wnl
BCS 5/9
EENT: OD hypermature cataract and possible anterior lens luxation, OS severe edema and buphthalmos. Blind OU with crusty d/c. Mild purulent nasal d/c. Right ear tip, mild debris AU
PLN: No enlargements noted
H/L: NSR, NMA,Lungs clear, eupneic with audible upper resp congestion
ABD: Non painful, no masses palpated
U/G: MN
MSI: Ambulatory x 4 but reluctant to move around cage even when handled, skin free of parasites, no masses noted, unkempt haircoat
CNS: Mentation appropriate but minimally responsive- absent menace

Assessment:
Geriatric
Dull/lethargic
URI
Blind OU – OS – r/o glaucoma vs neoplasia
OD – hypermature cataract and possible early anterior lens luxation
Underweight
Moderate dental dz
Leukocytosis with neutrophilia
Hyperglobulinemia
Mild hypothermia

Prognosis: Poor

Plan:
Temp-99.2 F
Rec IM workup with AUS
Start doxycycline 10mg/kg PO SID x10d until 1/24
Continue SQ LRS until 1/15
Continue TAB ointment until 1/15
Give one dose mirtazapine 3.75mg PO
Monitor closely, rec placement with hospital-if continues to decline may rec EHR due to poor prognosis
VET

13-Jan-2018

13-Jan-2018

13-Jan-2018

13-Jan-2018
Progress Exam
Vet Notes: 11:08 AM

Recheck eyes/general condition

S/O: Q/BAR. ~5% dehydration. Allows handling but startles very easily and tries to flee. No interest in food. Large pile of diarrhea in cage. RIGHT ear tipped (very clean ear tipping, does not appear to be trauma)
EENT: Pink mm, mild dental tartar/staining, hypermature cataract OD, corneal edema, mild buphthalmia with raised corneal defect OS, no active nasal discharge, mild nasal crusting, sounds congested
HL: Normal thoracic auscultation
INTEG: Dirty, unkempt hair coat
MS: Ambulatory x 4
UG: Neutered

A: Geriatric
Mild dehydration
Blind
Underewight

P: Scheduled CBC/Chem/T4. Rec LRS 100ml SQ q24 x 3 days. Fair prognosis
VET

12-Jan-2018
DVM Intake
Vet Notes: 6:10 PM

[DVM Intake]
DVM Intake Exam

Estimated age: 8-10 yrs
Microchip noted on Intake?
Microchip Number (If Applicable):

History : stray

Subjective: qar, blind ou

Observed Behavior – allows exam, but tense and will try to bite occ’l

Evidence of Cruelty seen -n

Evidence of Trauma seen – possible – blood and bruising to nose and eyes

Objective

T = 93.7 (hypothermic)
P = 160 bpm
R = wnl
BCS 4/9

EENT: ears scant waxy debris, abrasion to nose, brown debria ou. OD hypermature cataract and +/-early anterior lens luxation, OS severe edema and buphthalmus and cannot retropulse OS. Blind OU
Oral Exam: missing many teeth and mod pdz on remaining, cannot open mouth
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, 5% dehydrated, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G: mn
MSI: Ambulatory x 4, skin free of parasites, no masses noted, dull, dry haircoat, wet from being in rain, sarcopenic, abrasion to nose
CNS: Mentation appropriate – BLIND
Rectal: ne

Assessment: approx. 8-10 yr mn dsh
hypothermia
dehydrated
Blind OU – OS – r/o glaucoma vs neoplasia
OD – hypermature cataract and possible early anterior lens luxation
underweight/sarcopenic
mod dental dz

Prognosis: Eyes – If neoplasia poor
If glaucoma – poor for vision, but good for management/comfort
Possible trauma

Plan: dried hair w/ hair dryer and placed on heat source. Monitoring temp hourly until >99
100 cc LRS sq
0.44 cc simbodol sq
retro test – neg
fluoro stain – neg ou
tab +H bid OS
feed and monitor temperature
recheck in am
consider tonometry and chest rads to r/o neoplasia

RE-CHECK TEMP in 30 min – increased to 94.1

SURGERY:
N/A
VET-P

For more information on adopting from the NYC AC&C, or to find a rescue to assist, please read the following: http://urgentpodr.org/adoption-info-and-list-of-rescues.

If you are local to the Tri-State, New England, and the general Northeast United States area, and you are SERIOUS about adopting or fostering one of the animals at NYC ACC, please read our MUST READ section for instructions, or email [email protected]. Our experienced volunteers will do their best to guide you through the process.

* We highly discourage everyone from trusting strangers that send them Facebook messages, offering help, for it has ended in truly tragic events.*

For more info on behavior codes and ratings, please click here: http://information.urgentpodr.org/acc-placement-status-descriptions.

For answers to Frequently Asked Questions, please see: http://information.urgentpodr.org/category/frequently-asked-questions/.

You can call (212) 788-4000 for automated instructions.

Previous | Next