CARMEN – A1123405
Safe - 9-12-2017 Brooklyn
SAFE 9/12/17 Carmen was recently adopted and returned because she became inappetent, dehydrated, and lethargic. She needs follow up medical care to address any possible underlying issues. CARMEN was brought in by her owner along with 3 adoptable age kittens due to landlord issues. She needs a new home asap!
Brooklyn Center
*RETURN*
Carmen A1123405, 2 Years Old, Brown Tabby DSH, Spayed, 4.5 lbs, Owner Surrender 09/05/17
Medical::
08/28/17:
DVM Intake Exam
Estimated age: 2 years
Microchip noted on Intake? no
History : surrender
Subjective: BAR, hydrated
Observed Behavior – quiet, calm, allows handling/exam with minimal restraint.
Evidence of Cruelty seen – no
Evidence of Trauma seen – no
Objective
P = 120 R = 20 BCS: 4/9
EENT: Eyes clear, ears clean, no nasal discharge noted
Oral Exam: negative oral exam
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G: female intact, no mgts or dc
MSI: Ambulatory x 4, skin free of parasites, no masses noted, mild miliary dermatitis around head and neck, no parasites noted
CNS: mentation appropriate – no signs of neurologic abnormalities
Assessment: mild miliary dermatitis as above otherwise in good health
Plan: continue to monitor at BACC
Prognosis: excellent
SURGERY: Okay for surgery
08/29/17:
Pre-surgery exam
S/O: QAR. Resting in cage
EENT: Eyes clear, no ocular or nasal discharge
HL: No sneezing
A: Apparently healthy
P: Based on chart review and no signs of URI, OK for surgery tomorrow
08/30/17:
Pre-surgical exam, anesthesia, and surgery performed by ASPCA. Green linear tattoo placed on ventral abdomen.
09/05/17:
Adopters brought in today for vomiting, diarrhea, lethargy, and decrease in appetite since 9/1.
Subjective: QAR and ~7% dehydrated (prolonged skin tent, sunken eyes, dry gums). Very lethargic and weak. she has lost 1.3 pounds since her last weight in the shelter.
Objective
P = wnl R = wnl BCS 3/9
EENT: no nasal d/c, mild mucoid ocular d/c ou, ears are clean
Oral Exam: clean adult dentition, no oral ulcers, no fb under tongue
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic
ABD: Non painful, no masses palpated
U/G: FS, no vulvar d/c, no MGTs
MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy haircoat, spay incision cdi
CNS: mentation appropriate – no signs of neurologic abnormalities
Assessment:
Dehydration
Lethargy
Vomiting r/o infectious vs IBD vs neoplasia vs FIP vs other
Diarrhea
Inappetence
Hypochloridemia and hyponatramia r/o v/d
Hyperglobulinemia
Hyperproteinemia
Hyperglycemia r/o stress vs DM
Monocytosis r/o infectious vs inflam vs stress
Thrombocytopenia r/o clumping
Plan:
Parvo snap-negative
LRS SQ 25ml/kg
Cerenia 1mg/kg SQ
Rec hospitalization at rDVM for severe dehydration
2 view AXR/CXR-nsf, no obvious foreign bodies, obstruction, or masses
CBC-monocytosis 1.86 (0.05-0.67), suspect bands, thrombocytopenia 67 (151-600) r/o due to platelet clumping
Chemistry-hyperglobulinemia 5.2 (2.8-4.8), hyperproteinemia 8.5 (5.2-8.2), hyperglycemia 197 (77-153), hypochloridemia 105 (115-126), hyponetremia 147 (150-165)
Place IVC
Start doxycycline 10mg/kg PO SID x14d
Give LRS 20ml/kg bolus then 180 ml/kg/day CRI
Recheck daily
Prognosis: Fair
09/06/17:
Recheck: vomit/diarrhea/dehydration
QAR, better hydrated today, still has some skin tenting and tacky mm
EENT: nsf
PLN: wnl
H/L: 120 regular, no murmurs, ssp, resps are clear and eupnic
ABD: not deeply palpated, but no obvious masses or pain
U/G: female recently spayed
MSI: thin, ok coat, strongly ambulatory x 4, OHE site is slightly irritated, but dry and intact.
Neuro: quiet, but no deficits.
A:
dehydrated, better today
diarrhea: soft, but formed stools noted in litter, good urine production
see eating some canned food after exam, no evidence of vomit in kennel
rule out inflamm vs infectious vs secondary to OHE/anesthesia vs other
P: continue iv fluids during the day, consider analgesics (simbadol). recheck daily
09/07/17:
Recheck dehydration/nausea/vomiting
BAR, appears hydrated today, no evidence of vomit or diarrhea in kennel. Appears to be eating and drinking well.
EENT: nsf
ABD: soft, no pain or masses
MSI: a little thin, ambulatory x 4, good coat, OHE incision is clean, dry and intact
U/G: f/s
Neuro: nsf
H/L: nsf
A: stable, vomit/dehydration appears resolved
P: remove iv catheter today, monitor appetite/attitude next few days.
09/08/17:
Monitor hydration, nausea, appetite
S/O: Q/BARH. Allows all handling but low body posture, tries to flee, allows all handling. Clean litter, fresh food available, no interest
EENT: Eyes clear, no ocular or nasal discharge, pink mm
HL: Normal thoracic auscultation
ABD: Soft, non tender
INTEG: WNL
MS: Ambulatory x 4
UG: Spayed, incision healing well
A: HX of anorexia, vomiting, dehydration – condition improving
P: Rec LRS 50ml Sq q24 x 3 days, mirtazipine 1/4 tab PO. Continue to monitor. Good prognosis
09/09/17:
Monitor hydration, nausea, appetite
S/O: Q/BARH. Allows all handlingClean litter, fresh food available – ate very well this morning
EENT: Eyes clear, no ocular or nasal discharge, pink mm
HL: Normal thoracic auscultation
ABD: Soft, non tender
INTEG: WNL
MS: Ambulatory x 4
UG: Spayed, incision healing well
A: HX of anorexia, vomiting, dehydration – condition continuing to improve
P: Continue with current treatment and monitoring plan. Good prognosis
Behavior::
KNOWN HISTORY:
Lived Indoors
Previously lived with: Adults
Behavior toward strangers: Shy for a few minutes then becomes friendly
Behavior toward children: Unknown
Behavior toward cats: Relaxed and gentle
Behavior toward dogs: Unknown
Bite or Scratch history: None
Litter box training: Yes
Energy level/descriptors: Friendly, quiet, and affectionate with a high activity level.
MEDICAL BEHAVIOR:
Quiet, calm, allows handling/exam with minimal restraint.
ENRICHMENT NOTES:
08/29/17
Lying in litter box, ears forward and eyes alert. She allows petting along her head and body, leaning in. Eyes are soft. Begins to purr. Doing well!
EVALUATION:
Cage Condition: Cage is neat
Reaction to assessor: Carmen was sitting at the front of the kennel with her paws folded under her body.
Reaction when softly spoken to: Carmen rolls over on her side, rubs against the cage furnishings and kneads on her blanket.
Reaction to cage door opening: Carmen is calm and relaxed.
Reaction to touch: Carmen rolls around playfully, gives head butts and purrs softly when pet along her body.
Reaction to being picked up: Carmen is calm, relaxed and has a soft body when held.
ACTIVITY LEVEL: Lively
VOCAL: Quiet
CHARACTER TYPE: Calm, Sweet, Affectionate
BEHAVIOR SUMMARY: Beginner
Carmen interacts with the Assessor, solicits attention, is easy to handle and tolerates all petting. No known history of behavioral problems. This cat can go to a beginner home.
Enrichment::
08/29/17:
Lying in litterbox, ears forward and eyes alert. She allows petting along her head and body, leaning in. Eyes are soft. Begins to purr. Doing well!
09/06/17:
At front of kennel. Makes eye contact and raises tail when spoken to. She allows petting along her head and body while leaning in and purring softly. Doing well after first day! Doesn’t seem to be bothered by her I.V. Sprayed feliway.
Profile::
08/28/17:
Carmen is a 2 year old unaltered female and she came to her home as a stray and was surrendered due to the owner having personal problems. Carmen has no known health issues or injures and has no vet history.
Around strangers Carmen is shy for minutes but becomes friendly and allows the soft petting. She has never been around children and has lived other cats and is gentle and relaxed, and she has no bite history.
Carmen isn’t bothered when given a bath or held. She was described as friendly, quiet, and affectionate with a high activity level. She sleeps in the basement and is free feed dry food. Carmen is house trained and uses an uncovered litter box, with clumping litter.
Upon intake Carmen was a little nervous but allowed the counselor to collar and take a photo.
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PREVIOUS INFO:
WAS SAFE 9/1/17
BROOKLYN CENTER
CARMEN – A1123405
SPAYED FEMALE, CALICO, DOMESTIC SH MIX,2 yrs
OWNER SUR – AVAILABLE, NO HOLD Reason LLORDNYCHA
Intake condition EXAM REQ Intake Date 08/28/2017, From NY 11206, DueOut Date 08/28/2017, I came in with Group/Litter #K17-109374.
Medical Behavior Evaluation GREEN
Medical Summary DVM Intake Exam Estimated age: 2 years Microchip noted on Intake? no History : surrender Subjective: BAR, hydrated Observed Behavior – quiet, calm, allows handling/exam with minimal restraint. Evidence of Cruelty seen – no Evidence of Trauma seen – no Objective P = 120 R = 20 BCS: 4/9 EENT: Eyes clear, ears clean, no nasal discharge noted Oral Exam: negative oral exam PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: female intact, no mgts or dc MSI: Ambulatory x 4, skin free of parasites, no masses noted, mild miliary dermatitis around head and neck, no parasites noted CNS: mentation appropriate – no signs of neurologic abnormalities Assessment: mild miliary dermatitis as above otherwise in good health Plan: continue to monitor at BACC Prognosis: excellent SURGERY: Okay for surgery
Weight 5.8
CAME IN WITH (KITTENS)
A1123406 – TONY
A1123407 – RAVEN
A1123408 – CHANCE
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View all entries in: Safe Cats 2017-09