ERIE – 12103

Staten Island Center

12103 – Erie – 15 year neutered male – Stray

Vet Notes: 4:07 PM
azotemia (BUn=80, crea 3.1)- R/O kidney disease vs dehydration vs other
hyperphosphatemia- R/O renal disease vs other
hyperglobulinemia- R/O chronic infection vs inflammation vs neoplasia vs other
anemia (hematocrit= 19.1)- R/O renal disease vs neoplasia vs bone marrow disease vs other
neutrophilia, monocytosis- R/O infection vs inflamamtion vs neoplasia vs other
VET 991385
9-Nov-2017
DVM Intake
Vet Notes: 3:31 PM
[DVM Intake]
DVM Intake Exam

Estimated age:15 years

History : stray

Subjective:

Observed Behavior – depressed; tolerated exam

Evidence of Cruelty seen -no

Evidence of Trauma seen -no

 

Objective

 

BCS 3/9

EENT: OU- corneal opacity, green mucoid discharge, ears clean, severe amount of purulent nasal discharge
Oral Exam: missing several teeth; mm’s pale pink
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic
ABD: Non painful, no masses palpated
U/G: MN
MSI: Ambulatory x 4, large amount of flea dirt, no masses noted, patches of fur loss, severely decreased skin turgor
CNS: Mentation appropriate – no signs of neurologic abnormalities

Assessment
fleas
nasal and ocular discharge- R/O URI vs other
emaciated- R/O GI disease vs renal disease vs endocrine disease vs other
patches of alopecia- R/O flea allergy vs endocrine disease vs other

Prognosis: guarded to poor

Plan:
SQ LRS fluids 75 mls x 3 days
continue doxycline
start erythromycin OU BID x 10 days
CBC/chemistry
VET 991385
8-Nov-2017
LVT Intake
L V T Notes: 3:55 PM
Bar.
moderate dehydration.
Scan negative.
Neutered ~ 15 years old
Ambx4
Ear waxy
Nasal discharge seen
Blind
Dental disease , emaciated.
As per Dr. 1382
100 ml S/Q fluid
0.3 ml cerenia S/Q
0.6 ml Doxycycline X 10 days

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