EVIE – 22107
Safe - 5-12-2018 Brooklyn
SAFE 5/12/18 – Evie has had a lot going on in the two times she’s been at the Brooklyn Care Center, not including her trips to and from her previous foster home! She no longer has a URI, her abdomen appears to no longer be distended, and her woods lamp test and DTM are negative for ringworm. The vet recommends that she receive an echocardiogram prior to spay surgery just to be safe, and her dermatitis, fractured tooth, and missing toe are all of no real concern. She’s a real sweetie and deserves to go to a forever home!
Brooklyn Center
*RETURN*
Evie 22107, 1-3 Years Old, Gray Tabby DSH, Stray 05/04/18
Medical:
22107
Evie
Cat
Yes
Torbie
None
Female
Spayed / Neutered
Age
Primary Microchip #
Rabies Tag
Weight
Spay / Neuter Due Date
Temperature
No
2 Years 2 Months (approx)
5 lbs 10.56 oz
Veterinary Clinic Software Record #:
Weight: 5 lbs 10.56 oz
Date of Weighing: 5/5/2018
Date Spayed / Neutered:
Schedule Surgery Date:
Stitches Removal Date:
Clinic Name:
Previously Spayed / Neutered: No
General Vet Notes:
Previous Medical Details:
Known Allergies or Medical Conditions:
Feeding Requirements:
Indemnities/Waivers:
Spay/neuter Waiver – Medical Condition
Your newly adopted pet has been diagnosed with Heart Murmur and the staff veterinarians are issuing a permanent waiver for spay/neuter. Follow up care at your regular veterinarian is recommended.
SO
presented for foster exam, determine if OK for OVH on 3/30.
-BAR, requires restraint. low growling and hissing during exam.
-no ocular discharge; no nasal discharge or crusting. no sneezing.
– fractured #204
-BCS 6/9
-no pain on abdominal palpation
-3/6 parasternal murmur ausculted
A
heart murmur
overweight
fractured #204.
P
permanent OVH waiver due to heart murmur
weight management
monitor fractured tooth. no root exposure at this time.
Medical Notes
Notes
Date
No Medical Notes Stored
Vet Treatments
Date Administered
Vet Treatment Type
Treatment Result
Administered by External Vet
3/4/2018
Internal Parasite Treatment – Pyrantel
3/4/2018
Flea/Tick Application – Topical
3/4/2018
FeLV/FIV Snap
Negative
3/4/2018
Fvr-Cp 1 Of 2
3/4/2018
Rabies
3/4/2018
Microchip Implantation
3/11/2018
Flea/Tick Application – Topical
3/14/2018
Fvr-Cp Annual
5/5/2018
Flea/Tick Application – Topical
5/5/2018
Re-weigh
Vet Treatments Due
Date Due
Vet Treatment Type
5/19/2018
Re-weigh
6/5/2018
Flea/Tick Treatment – Paradefense
3/4/2019
Rabies
3/18/2019
Fvr-Cp Annual
Medications
Medication
Amount Dispensed
Frequency
Date From
Date To
Doses Administered
Vet Name
Reason
Notes
Fortiflora (probiotic supplement)
0
1 sachet every 1 day(s)
4-Mar-2018
Indefinite
6
VET
Sprinkle on food once daily
Vitamin B Complex INJ
0 ml
0.25 ml SQ once
4-Mar-2018
4-Mar-2018
0
VET
Other Medication
0
Clean ears once every 3 day(s)
7-Mar-2018
After completed 3 times
0
VET
Clean both ears
Tresaderm
0 drops
6-10 drops AU, 2 times every 1 day(s)
4-Mar-2018
Indefinite
8
VET
Tresaderm
1 drops
3 drops once
11-Mar-2018
11-Mar-2018
1
Apply (3 drops) in both ears twice per day for 7 days
Fluids – LRS SQ
0 ml
100, 2 times every 1 day(s)
14-Mar-2018
16-Mar-2018
4
Cerenia (Maropitant) INJ 10 mg/ML
0 ml
0.3 every 1 day(s)
14-Mar-2018
16-Mar-2018
3
SQ
Vitamin B Complex INJ
0 ml
0.25 every 1 day(s)
14-Mar-2018
16-Mar-2018
3
SQ
Nebulize with saline
0 ml
1 every 1 day(s)
15-Mar-2018
16-Mar-2018
2
VET
Simbadol 1.8mg/ml
0 ml
0.4 ml SQ every 1 day(s)
16-Mar-2018
19-Mar-2018
1
VET
Erythromycin Opthal. Ointment 0.5%
1 tube
1 strip once
17-Mar-2018
17-Mar-2018
1
As per dr. dispensing 1 tube Erythromycin Opthal. Ointment 0.5% OU BID x 5 days—-to sonja
Drug Usage
No drugs administered to this animal.
Vet Consultations
Date
Reasons
Vet Notes
Vet
Date Resolved
6-May-2018
6-May-2018
DVM Intake
Vet Notes: 12:49 PM
DVM Intake Exam
Estimated age: ~2-4 years
Microchip noted on Intake? positive
History : stray found fighting outside with another cat, return (MC positive)
3/4-intake, started on B12 and fortiflora due to URI, tresaderm for suspect ear mites
3/8-distended abdomen noted
Lateral abdominal radiograph: copious amount of ingesta in stomach, multifocal gas distension throughout small intestine but no obstructive pattern; formed fecal material in colon; soft tissue structure present in ventrocaudal abdomen, suspected to be bladder; no deviation of colon and no obvious pyometra
3/11-DTM culture taken for alopecia (negative), given ivermectin and defensor. Wood’s lamp negative.
3/14-persistent URI, return from foster, given cerenia, B12, and SQ LRS.
3/15-returned from foster again for persistent URI, new HM noted, started on nebulization. PCR sent out (positive for herpesvirus).
3/16-started on simbadol for suspect oral pain due to URI
Subjective: BARH
Observed Behavior – Tense and nervous but allowed handling. Hissed with excessive handling. Did well for all medical handling and procedures
Evidence of Cruelty seen – no
Evidence of Trauma seen – no
Objective
P = wnl
R = eupneic
BCS 5/9
EENT: Eyes clear, ears clean with greasy substance around them, no nasal discharge noted
Oral Exam: adult dentition with mild staining and gingivitis, no oral lesions noted
PLN: No enlargements noted
H/L: NSR, Grade 3/6 HM, CRT < 2, Lungs clear, eupneic
ABD: Non painful, no masses palpated
U/G: FI, no MGTs, no vulvar d/c
MSI: Ambulatory x 4 with LHL lamness-missing digit 1 on LHL, skin free of parasites, no masses noted, healthy hair coat with some alopecia on dorsal tail base
CNS: mentation appropriate – no signs of neurologic abnormalities
Assessment:
Grade 3/6 HM
Missing digit 1 on LHL
Dorsal tail base dermatitis r/o FAD vs other
Fractured tooth #204
Plan: Continue to monitor while at BACC
Rec echocardiogram before spay
Prognosis: Good to fair
SURGERY: permanent waiver due to HM
VET
4-Apr-2018
RingWorm Culture-Final
Medical Assistant: 12:21 PM
24th day of DTM culture
made: 3/11/18
No growth or change of color seen in any of the sides.
Plate will be discarded.
ECT-VA
29-Mar-2018
Foster Exam
Vet Notes: 1:46 PM
SO
presented for foster exam, determine if OK for OVH on 3/30.
-BAR, requires restraint. low growling and hissing during exam.
-no ocular discharge; no nasal discharge or crusting. no sneezing.
– fractured #204
-BCS 6/9
-no pain on abdominal palpation
-3/6 parasternal murmur ausculted
A
heart murmur
overweight
fractured #204.
P
permanent OVH waiver due to heart murmur
weight management
monitor fractured tooth. no root exposure at this time.
VET
29-Mar-2018
Spay-Neuter Waiver Documentation
Vet Notes: 1:39 PM
[Spay/Neuter Waiver – Medical Condition]
Your newly adopted pet has been diagnosed with A HEART MURMUR and the staff veterinarians are issuing a permanent waiver from the spay/neuter requirements of the City of NY. Follow up care at your regular veterinarian is recommended to ensure continued treatment. Your veterinarian will advise you if surgical sterilization is appropriate.
VET
20-Mar-2018
Progress Exam
Vet Notes: 3:20 PM
Resp PCR panel is back: positive for herpes but no other organisms (including mycoplasma).
Continue current tx.
VET
16-Mar-2018
Progress Exam
Vet Notes: 2:26 PM
Hx: Foster cat who developed vial URI, on treatment with nebulization, vitamin B12, SQF, Cerenia.
S: Alert in kennel, slightly tense
O: BAR, skin of shoulders and front legs is slightly gelatinous. Pink MMs.
EENT: Thick hypersalivation. Clean teeth. Mild serous ocular and nasal discharge.
H/L: Sniffling, sounds very congested.
Abd: Soft, nonpainful
A: URI – suspect oral pain. Gelatinous skin of front legs is likely secondary to SQF administration.
P: Add Simbadol 0.4 ml SQ SID x4 days. If pt is looking better tomorrow, she may go home at that time.
VET
15-Mar-2018
Progress Exam
Vet Notes: 12:06 PM
Returned from foster due to worsening URI signs and inappetance; suspected viral so was started on cerenia, SQF, B12
S/O
-BAR, docile, friendly and affectionate; allows all handling
-great appetite today!
-mm pk, moist; CRT <2 sec
-mild to moderate nasal congestion, scant serous nasal discharge
-OU: mild blepharospasm
-eupnic, referred upper airway noise
-grade II/VI parasternal “squeaky” heart murmur noted today
-soft abdomen
A
1. URI
2. Heart murmur, new
P
-submit swab for resp PCR panel, if positive for mycoplasma then recommend starting doxycycline
-add nebulization SID x 2 days
-continue current treatments, if improving still then okay to return to foster
VET
15-Mar-2018
Tech Exam
L V T Notes: 10:30 AM
Administered 100mls LRS SQ, 0.3mls of Cerenia 10mg/ml SQ, 0.25ms Vitamin B12 SQ @ 10:04am.
LVT
15-Mar-2018
14-Mar-2018
Progress Exam
Vet Notes: 11:21 AM
History : client indicated that after visiting ACC for an examination 2-3 days prior for a ringworm ck, Evie started drooling and having nasal and ocular dis-c shortly after going home. She brought her back today for an exam of these clinical findings.
Subjective: QAR
Observed Behavior – gentle
Evidence of Cruelty seen – n
Evidence of Trauma seen – n
Objective
T = 101
P = 184
R = wnl
BCS = UR
EENT: Eyes clear with mild blepharospasm, ears clean, clear nasal discharge, no ocular dis-c
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G: NP
MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal: np
Assessment: Mild URI
Suspect viral due to the presence of clear nasal dis
Prognosis: Good
Plan:
Suspect viral so will not place on antibiotics unless otherwise indicated
-Gave 100 ml LRS SQ Fluids
-Gave 0.3 ml Cerenia
-Gave 0.25 ml Vit B Inj
Send home rx
– Cerenia 2mg/kg tablets PO SID for 3 days
Recheck in 7 days and send home with a foster
SURGERY:
Temporary waiver due to URI
VET
14-Mar-2018
Tech Exam
L V T Notes: 10:57 AM
Administered 0.25mls of Vit B12 SQ, 0.3mls of Cerenia SQ, 100MLS LRS SQ @ 10:55am.
VET
14-Mar-2018
11-Mar-2018
Progress Exam
Vet Notes: 2:18 PM
[DVM Intake]
DVM Intake Exam
History: Foster noted some ears of alopecia around the neck and the base of tail
Subjective: BAR
Objective
EENT: Ears still have black/brown debris and are pruritic, Eyes clear, ears clean, no nasal or ocular discharge noted
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G: Unremarkable
MSI: 2 patchy areas (1cm wide) of alopecia around around dorsal and ventral likely secondary to scratching ears, mild focal area of alopecia on base of tail, ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat
– WOODS LAMP NEGATIVE
– DTM CULTURE TAKEN FROM BASE OF TAIL AS A PRECAUTION
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal: NP
Assessment:
1) Otitis externa: Mites vs Bacteria vs Yeast
Note: Areas of alopecia suspected likely secondary to ear puritis and scratching of the neck vs over-grooming vs flea allergy
Plan:
Continue tresaderm OU BID for 7 days
Gave single dose of ivermectin
Gave single dose of defensor
DTM CULTURE TAKEN FROM BASE OF TAIL
VET
8-Mar-2018
Progress Exam
Radiograph Review
Vet Notes: 3:08 PM
Lateral abdominal radiograph: copious amount of ingesta in stomach, multifocal gas distension throughout small intestine but no obstructive pattern; formed fecal material in colon; soft tissue structure present in ventrocaudal abdomen, suspected to be bladder; no deviation of colon and no obvious pyometra
Vet Notes: 2:58 PM
Abdomen was noted to be somewhat distended by ACS
S/O
-BAR, docile and friendly
-good appetite
-no nasal discharge or sneezing
-OU: mild intermittent blepharospasms
-eupnic
-abdomen appears sl distended but is soft and nonpainful; no palpable uterus
A
1. Distended abdomen-r/o normal appearance for patient vs previous pregnancy vs early pregnancy
2. Conjunctivitis-possibly resolved
P
-okay to go to foster
-okay to spay if no conjunctivitis signs noted over the next 5-7 days
VET
8-Mar-2018
Tech Exam
L V T Notes: 2:43 PM
One view right lateral abdominal radiograph taken and reviewed by DVM 1382. Nails trimmed.
LVT
8-Mar-2018
8-Mar-2018
Tech Exam
L V T Notes: 2:42 PM
Nail trim completed.
LVT
8-Mar-2018
4-Mar-2018
Spay-Neuter Waiver Documentation
Vet Notes: 12:51 PM
SURGERY IS TEMPORARILY WAIVED FROM ACC DUE TO URI
VET
4-Mar-2018
4-Mar-2018
DVM Intake
Vet Notes: 12:49 PM
DVM Intake Exam
Estimated age: Estimated 1-3 years based on dentition and overall appearance
Microchip noted on Intake? Scanned negative – MC placed during exam
History : Abandoned in apartment, no health hx available
Subjective: Alert, moves slowly
Observed Behavior – Timid but allows all handling
Evidence of Cruelty seen – None
Evidence of Trauma seen – None
Objective
BAR-H, MMs pink and moist, BCS 5/9
EENT: Mild epiphora OU. Mild black discharge AU. Eyes clear, no nasal discharge noted
Oral Exam: Clean adult teeth, fractured left maxillary canine tooth
PLN: No enlargements noted
H/L: NSR, NMA, Lungs clear, eupnic
ABD: Slightly rounded, soft, non painful, no masses palpated
U/G: Female, no spay scar noted
MSI: Coarse hair coat, significant barbering at dorsal neck, tailhead and ventrum. One set of three short (5 mm long) superficial linear scratches on dorsal neck. Many crusts in the barbered regions. Ambulatory x 4, no masses noted.
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal: Normal externally
Assessment:
1. Ear mites likely
2. Conjunctivitis
3. Fractured tooth
Prognosis: Good
Plan:
1. Move to isolation
2. Give 0.25 ml vit B complex and Fortiflora SID x2 weeks
3. Spay after conjunctivitis resolves
4. Clean ears q3 days
5. Tresaderm AU BID
SURGERY:
Temporary waiver due to conjunctivitis
VET
Behavior:
This information is supplied as a guide only based on the history supplied to us and on our observations of the animal in the shelter. Animal Care Centers of NYC, its employees and agents accept no responsibility in the event that the animal behaved differently from its description above nor are any guarantees made in respect of its future behavior.
Animal Behavior Saved At: 8-May-2018 12:27:15.000
Animal ID:
22107
Animal Name: Evie
Age: 2 Years 2 Months (approx)
Tag Number:
Breed: Domestic Short Hair
Gender: Female
Spayed / Neutered: No
Behavior Assessment Date:
5/8/2018
KNOWN HISTORY:
Evie was brought in as a stray, so we don’t have any behavioral history or tendencies in a home environment.
MEDICAL BEHAVIOR:
05/06/18
Tense and nervous but allowed handling. Hissed with excessive handling.
Cage Condition:
Cage is neat
Reaction to assessor:
Evie was curled up and resting on her blanket near the back of the kennel.
Reaction when softly spoken to:
Evie lifts her head up to make eye contact, but she doesn’t come forward when coaxed.
Reaction to cage door opening:
Evie seems unsure of her surroundings and lowers her head.
Reaction to touch:
Evie sniffs the assessor’s hand, then tilts her head, allowing petting and rubs all over. She arches her body, and gives head butts, but appears to prefer being pet on her head. When the assessor’s hand passed along her back, she quickly whipped around, hissed and kept her eyes focused on his movements.
Reaction to being picked up:
Evie was tense when picked up, but she remains calm and allows all handling.
ACTIVITY LEVEL:
Mellow
VOCAL:
Quiet
CHARACTER TYPE:
Calm
Sweet
Affectionate
Curious
POTENTIAL CHALLENGES:
None
BEHAVIOR DETERMINATION:
Experience
Behavior Asilomar
TM – Treatable-Manageable
RECOMMENDATIONS:
None
BEHAVIOR SUMMARY:
Evie may be a little more independent, and may need time to warm up to her new home. We recommend that this cat go to a home with experienced cat parents.
Other:
3/8/18 Beginner 05/08/18 Behavior: Experience
*********************************************************************************************************
PREVIOUS INFO:
WAS SAFE 4/1/18
MANHATTAN CENTER
Evie 22107
Care Center Location: Manhattan
ZIP Code From: 10458
Intake Type: Stray
Medical Behavior: Green
Age: 2 years
Sex: Female
Weight: 5 lbs
DVM Intake Exam
Estimated age: Estimated 1-3 years based on dentition and overall appearance
Microchip noted on Intake? Scanned negative – MC placed during exam
History : Abandoned in apartment, no health hx available
Subjective: Alert, moves slowly
Observed Behavior – Timid but allows all handling
Evidence of Cruelty seen – None
Evidence of Trauma seen – None
Objective
BAR-H, MMs pink and moist, BCS 5/9
EENT: Mild epiphora OU. Mild black discharge AU. Eyes clear, no nasal discharge noted
Oral Exam: Clean adult teeth, fractured left maxillary canine tooth
PLN: No enlargements noted
H/L: NSR, NMA, Lungs clear, eupnic
ABD: Slightly rounded, soft, non painful, no masses palpated
U/G: Female, no spay scar noted
MSI: Coarse hair coat, significant barbering at dorsal neck, tailhead and ventrum. One set of three short (5 mm long) superficial linear scratches on dorsal neck. Many crusts in the barbered regions. Ambulatory x 4, no masses noted.
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal: Normal externally
Assessment:
1. Ear mites likely
2. Conjunctivitis
3. Fractured tooth
Prognosis: Good
Plan:
1. Move to isolation
2. Give 0.25 ml vit B complex and Fortiflora SID x2 weeks
3. Spay after conjunctivitis resolves
4. Clean ears q3 days
5. Tresaderm AU BID
SURGERY:
Temporary waiver due to conjunctivitis
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.
View all entries in: Safe Cats 2018-05