GEMMA – 28019

Vet Consultations
Date
Reasons
Vet Notes
Vet
Date Resolved
16-May-2018
Progress Exam
Vet Notes: 4:46 PM

S/O – Eating and drinking. Responsive to touch and vocalizes.

Hydration status normal – no prolonged skin tent

Delayed menace response – minimally visible

Eyes- OU Miosis suspect secondary to hypertension

A – No deterioration in health

P – Continue on current tx plan
VET 991493

15-May-2018
Other Lab Interpretation
Vet Notes: 1:35 PM

Presented with history of persistent vocalization, blood work showed mild azotemia and signs of dehydration

BP: average MAP 180 mmHg

Urinalysis (voided sample)-USG 1.036, 3+ proteinuria, 3+ leukocytes, glucose/ketones neg, cocci present

A
1. Hypertension, r/o secondary to renal disease vs primary hypertension
2. Proteinuria-r/o UTI vs protein losing nephropathy
3. Cocci, WBC in urine-r/o contamination vs UTI

P
-amlodipine 2.5 mg tab: 1/4 tab PO SID
-clavamox drops: 0.8 ml PO BID X 10 days
-recommend rechecking BP, renal values, urinalysis in 10-14 days; if protein still present in urine, then consider urine protein:creatinine ratio to determine whether to add ACE-I long term
VET 991382

15-May-2018
Tech Exam
L V T Notes: 12:00 PM

Systolic BP- 180.
In house UA performed and uploaded to SB.
LVT-E 991215
15-May-2018
14-May-2018
Blood Work Interpretation
Vet Notes: 5:19 PM

CBC-elevated hct (56.3)

Chemistry-mild hyperglycemia (220), mild azotemia (creat 2.2, BUN 47), mild hyperglobulinemia

A
1. Azotemia, suspect CKD +/- dehydration
2. Elevated hct-suspect dehydration

P
-100 ml SQF SID x 3 days then once every 3 days
-recommend blood pressure, concern for secondary hypertension due to persistent vocalization
-urinalysis
-monitor appetite, ideally would be on renal diet
-recheck chemistry in 7-10 days
VET 991382

14-May-2018
DVM Intake
Vet Notes: 4:00 PM

DVM Intake Exam
Estimated age: 12-14 years
Microchip noted on Intake? neg
Microchip Number (If Applicable):

History :stray cat found in building, finder stated she had been vocalizing for about a week before she was brought the MACC

Subjective:BAR

Observed Behavior -friendly and affectionate, allows all handling; constant vocalization

Evidence of Cruelty seen -n

Evidence of Trauma seen -n

Objective
BCS 5/9

EENT: OU-pupils dilated and nonresponsive, visual, immature cataracts, iris atrophy; ears clean, no nasal or ocular discharge noted; possible thyroid nodule
Oral Exam:mm pk, moist; moderate tartar/staining
PLN: No enlargements noted
H/L: grade II/VI parasternal heart murmur, eupnic, clear lung sounds
ABD: Non painful, no masses palpated
U/G: female
MSI: Ambulatory x 4, skin free of parasites, no masses noted, unthrifty hair coat with moderate matting along dorsum; patch of crusting dermatitis along L neck, pruritic
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal:grossly normal

Assessment
1. Absent PLR-r/o cataracts and iris atrophy vs retinopathy vs other
2. Geriatric underlying
3. Dermatitis
4. Matted
5. Persistent vocalization

Prognosis:fair

Plan:
-CBC/chem/T4
-convenia 0.35 ml SQ
-shave for spay scar and shave matts

SURGERY:permanent waiver due to geriatric
VET 991382

14-May-2018
Spay-Neuter Waiver Documentation
Vet Notes: 12:16 PM

[Spay/Neuter Waiver – Age]

It is the policy of ACC not to perform surgery on any animal over the age of 8-10 years due to the higher risks incurred in a shelter setting. The veterinarian is hereby issuing a permanent spay/neuter waiver, from the spay/neuter requirements of the City of NY due to the estimated age of this animal. ACC does recommend you consult with your veterinarian to determine if surgical sterilization is appropriate.

Behavior

ENRICHMENT NOTES:
Just returned from medical exam. Resting on bedding, soft posture, eyes dilated but likely due to age. Lay in place when door opened. Sniffed hand, then leaned and arched into pets, purred quietly. Ate offered treats, then lay down again and appeared to doze off.