BLESSED – 23082

Brooklyn Center

Blessed 23082 – 8 yr. spayed white w/ orange kitty, stray:

 

ENRICHMENT NOTES:

03/18/18
Lying in back of kennel, body tense. Flattens ears and watches bear-claw as it reaches forward. Hisses and jerks head back when scratcher makes eye contact. May be uncomfortable due to medical condition. Needs more time to adjust.

Spay/Neuter statusYesDate of Intake17-Mar-2018
Basic Information:Blessed came in as a stray history is unknown. She is approximately an 8 year old, DSH female who is spayed.
Behavior Notes:Blessed was growling and did not allow for any handling with counselor.

19-Mar-2018

Progress Exam

Vet Notes: 8:54 AM

Progress exam

History: Intake 3/17. Given SQ LRS, cerenia, and famotidine.
CBC: nsf
Chemistry: mild hyperglobulinemia 5.9 (2.8-5.1), ALT moderately elevated 552 (12-130), ALP mild-moderately elevated 257 (14-111)
GGT moderately elevated 18 (0-4), t-bili 3.2 (0.0-0.9), Cholesterol mildly elevated 248 (65-225)
T4: 1.9 (Normal)
UA: 3+ bilirubin, 1+ protein, 2+ WBCs, USG >1.050
3/18-given cerenia and SQ LRS in net

Subjective: BAR. Limited cage exam due to behavior/stress. Has been eating some dry food. No csvd. U yesterday but empty litter box this morning. Unable to medicate cat in shelter because stress is very high for this cat. Will give medications in net once a day but ultimately needs hospitalization for IVC and IV medications.

Objective
EENT: Eyes clear, no nasal or ocular discharge noted
H/L: Normal RR/RE, eupneic
MSI: Ambulatory x 4, skin free of parasites, no masses noted, GHC, icteric pinna
CNS: Mentation appropriate – no signs of neurologic abnormalities

Assessment:
Icterus r/o hepatic lipidosis vs other liver disease
Decreased appetite
Mild hyperglobulinemia DDx: chronic inflammation, hepatic dz, FIP, immune mediated, neoplasia
ALT moderately elevated r/o hepatocellular injury from hepatitis, neoplasia, etc
ALP mild-moderately elevated 257 (14-111) r/o cholestasis vs other liver disease
GGT moderately elevated 18 (0-4) cholestasis
Elevated tbili with bilirubinuria r/o decreased hepatic uptake, decreased functional liver mass, decreased bile excretion
Cholesterol mildly elevated r/o liver dz, pancreatitis, etc

Prognosis:
Fair to poor

Plan:
CTM while at BACC
Rec hospitalization for e-tube placement, IVF, IV abx and pain meds. Will need AUS to assess liver and gallbladder.
Start SQ LRS 100ml SID x3d until 3/21
Start cerenia 1mg/kg SQ SID x3d until 3/21
Start B12 0.1ml SQ SID x3d until 3/21
+/- IVC with sedation if not NH placed soon

18-Mar-2018

Progress Exam

Vet Notes: 3:51 PM

[Progress Exam Template]

S: BAR in back of cage, no eating today
caught in net to try to deliver fluids and cerenia

O:
EENT: cannot examine w/o sedation
Oral Exam: cannot examine w/o sedation
H/L: ”
Abd: ”
MSI:
Mentation: not handleable at all, reactive to the slightest touch
A: r/o hepatic lipidosis – secondary to starvation vs underlying hepatopathy vs pancreatitis vs ibd vs neoplasia

P: 100 cc lrs sq -unable to give most of dose as pet
0.4 cc cerenia sq –
tomorrow reconsider sedation for more complete exam and radiographs
Needs abdo u/s w/ fna or biopsy
feeding tube
Px: guarded to poor due to overall guarded nature of the condition and temperament of the cat.

Is the Initial Medical Status being Changed?
New Medical Status:n
Is the Initial Behavior Status being Changed?
New Behavior Color: n

17-Mar-2018

Blood Work Interpretation

Vet Notes: 5:14 PM

Hematology
RBC – mildly decreased 6.28 (6.54-12.2)
Hematocrit – low normal 30.3 (30.3-52.3)
Monocyte – mildly elevated 0.71 (0.05-0.67)

Chemistry
Globulin mildly elevated 5.9 (2.8-5.1) DDx: chronic inflammation, hepatic dz, FIP, immune mediated, neoplasia
ALT moderately elevated 552 (12-130); hepatocellular injury DDx: hepatitis, neoplasia, open
ALP mild-moderately elevated 257 (14-111); cholestasis
GGT moderately elevated 18 (0-4); cholestasis
Bilirubin – Total 3.2 moderately elevated (0.0-0.9); dec hepatic uptake, dec functional liver mass, dec bile excretion
Cholesterol mildly elevated 248 (65-225) DDx: liver dz, pancreatitis, open

Total T4 – 1.9 (Normal)

Urispec 11-Way
Blood Ery – ca. 10
Urobilinogen – neg.
Bilirubin – +++
Protein – 100
Nitrite – neg.
Ketones – neg.
Ascorbic Acid – ++
Glucose – neg.
pH – 6
Leucocytes – ca. 500
USG (refractometer) – >1.050

Assessment: Icterus secondary to liver disease DDx: Hepatic lipidosis, FIP, Neoplasia, Open

PROGNOSIS:
Fair-Poor depending on diagnosis

Plan: Recommend NH placement. Recommend Internal Med consult with AUS on placement.

VET-P 991167

17-Mar-2018

DVM Intake

Vet Notes: 1:51 PM

DVM Intake Exam

Estimated age: 8-10yrs
Microchip noted on Intake? no
Microchip Number (If Applicable):

History: Blessed was brought in by police as a stray that was found in the car of someone who was arrested

Subjective: Cat is Q/BAR

Observed Behavior – hissing and growling in carrier, lunges and swats when approached, allowed handling during intake so suspect cat has escalated due to fear and/or overstimulation. Sedated with 0.1mLs Telazol IM, which provided adequate sedation for exam and treatments, continued to growl even after sedation.

Evidence of Cruelty seen – no

Evidence of Trauma seen – no

Objective

T = NA
P = wnl
R = wnl
BCS 4/9

EENT: Eyes clear, ears clean, no nasal or ocular discharge noted
Oral Exam: Grade 1-2/4 dental dz
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G: female, visible spay scar; Bladder large but soft, easily expressed; urine is dark yellow and stains fur
MSI: Ambulatory x 4, skin free of parasites, no masses noted, hair coat unkempt, skin yellow
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal: not performed

Assessment: Icterus. Rule-out anemia vs liver dz.

Prognosis:
Fair

Plan: Keeping in medical. Performing bloodwork & UA. Gave approx 100mLs SQ LRS. Gave 0.4mLs Cerenia and 0.2mLs Famotidine SQ.

SURGERY:
Already spayed

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