GOLDY – 33937

Y Female 5.12lbs.

Brown & White DSH

Intake: Stray 7/10/18

Medical:

Vet Consultations
Date
Reasons
Vet Notes
Vet
Date Resolved
13-Jul-2018
Progress Exam
Vet Notes: 10:13 AM

S/O – Pt QAR. Inappetent. Lethargic. Lying at back of kennel. Will growl when handled but will allow a full PE

EENT – Mild blepharospasm. No ocular or nasal nasal discharge.

Abdominal Palpation – soft. no masses palpated.

HR – 180
T – 104
R – wnl

A
– Hyperthermia
– Lethargy
– Inappetence
– Hydration restored

R/O Infectious causes (e.g. pyelonephritis, toxocara cati)

P
+ Continue on current treatment plan
+ Potassium Supplementation 30 MEQ (15ml) added to CURRENT full 1 litre bag of IV fluids
+ Mirtazapine 1/4 tab Once only
+ Enrofloxacin 2.5 mg/kg BID IM FOR 3 DAYS
+ Collect urine for urine culture – send to IDEXX

RECOMMEND AN ABDOMINAL ULTRASOUND, TOXOCARA CATI TITRES

12-Jul-2018

12-Jul-2018
Tech Exam
L V T Notes: 2:10 PM

As per Dr. 1493, pulled blood for a CBC/Chem to be run at Idexx and sedated rads of the abdomen and pelvis. Included results of CBC/Chem that was run at ACC. Used left saphenous vein for blood, took 4 x-rays: Abdominal right Lateral and V/D, and
Pelvic right Lateral and V/D.

Sedate – Dexmeditomidine 0.1 ml Butorphanol 0.1 ml IV, and Reversed with antisedan 0.05mls IM.

Idexx pick-up scheduled for after 8:30 pm on 7/12, confirmation # 10945.

12-Jul-2018

12-Jul-2018
Progress Exam
Vet Notes: 10:42 AM

S/O QAR More energetic than on intake exam but still lethargic /dull. No appetite. Urinating in kennel. Sitting up-right in kennel

EENT – no signs of nasal or ocular dis. No sneezing. OU Blepharospasm.

HR – 180
R – 30
T – 102.7 (Mild hyperthermia)
CRT <2 mmb pink + wet

Abdomen – Comfortable. No signs of pain. Soft. Bladder full.
MSK – Ambulatory x 4

Skin tent – normal

A
– Mild Hyperthermia – r/o infectious causes
– Still Lethargic – although energy improved in comparison to intake exam
– Hydration restored
– Inappetent
– No longer painful on abdominal palpation – suspect analgesia controlled by Simbadol

P
– Continue on current treatment plan
– Schedule for abdominal x-ray and CBC/CHEM (to be sent to IDEXX for additional interpretation)
+ Medical feeding – tempt with tuna and A/D

11-Jul-2018
Progress Exam
Vet Notes: 9:16 AM

S/O – Pt remains dull and lethargic. Quiet in kennel but a Mild improvement in energy compared to when pt came in on intake. Swatted at DVM during heart auscultation. Not eating. Urinated in the litter box.

EENT – no discharge from eyes or nose. Mild blepharospasm- pain?

HR – 200
R – wnl
T – 102.3
CRT< 2 mmb pink + wet

Skin tent mildly prolonged – dehydration 3-5%

Abdomen – discomfort on palpation of abdomen. No masses palpated. Rule out abdominal pain v pelvic pain

MSK – no pain on palpation of dorsal spine. Pt is weight bearing on all four but lethargic

A – Discomfort on abdominal palpation – r/o abdominal pain (e.g. pancreatitis) vs pelvic pain (traumtic injury)
– Normal temperature restored
– Lethargy
– Dehydration improved but still 3-5% dehdyrated
– Inappetent

P
– Increase fluids from 15ml/hr to 20ml/hr for 12 hrs
– Schedule abdominal and pelvic xrays for 7/12/2018 xrays
– Simbadol 0.3 ml SQ SID for 3 days

10-Jul-2018
Spay-Neuter Waiver Documentation
Vet Notes: 2:29 PM

[Spay/Neuter Waiver – Medical Condition]

Your newly adopted pet has been diagnosed with AN ILLNESS and the staff veterinarians are issuing a temporary 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.

10-Jul-2018
Blood Work Interpretation
Vet Notes: 1:59 PM

CBC/Chem

High end of range for HCT – dehydration
Mild Leukocytosis (26) with a Neutrophilia (20.92) – r/o infectious vs inflammatory

Marked elevation in BUN (130), – azotemia – r/o pre-renal vs renal vs post renal

Hyperphosphatemia (16.1), hypochloremia (87)

Elevated TP (10.9) with elevated albumin (4.2) and elevated globulins r/o – Dehydration, Chronic inflammation, Infection, Neoplasia

Moderate elevation in ALT (680) and Bilirubin (1.6) -r/o liver disease secondary to infectious, toxins and neoplasia,

a – Mild Leukocytosis, Neutrophilia, Azotemia, electrolyte imbalances, elevated liver enzymes, elevated protein

P
– continue on current tx plan include fluid therapy
– check blood work in 48 hours

+ Clavamox suspension (62.5mg) give 1 ml BID for 21 days
+ Monitor vitals throughout the day

10-Jul-2018
Tech Exam
L V T Notes: 11:47 AM

Placed 22g IV catheter cephalic. Started LRS at 11:45AM – 20mls/hr. Placed snuggie disk in cage for heat support.

10-Jul-2018
DVM Intake
Vet Notes: 10:57 AM

[DVM Intake]
DVM Intake Exam

Estimated age: 3
Microchip noted on Intake? n
Microchip Number (If Applicable):

History: stray

Subjective: lethargic, dull

Observed Behavior – gentle

Evidence of Cruelty seen –
n
Evidence of Trauma seen –
n

Objective

T = 95 F
P = 180
R = wnl
BCS = 3/9

Dehydration 7%

EENT: Eyes clear, ears clean, no nasal or ocular discharge noted
Oral Exam: teeth in good cond – no fractures or trauma
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Painful on palpation of abdomen
U/G: Female – suspect intact
MSI: Paresis
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal: externally normal

Assessment
– Dehydration 7%
– Hypoerthermia
– Lethargy
– Pain on Abdominal palpation

Prognosis: Poor to Fair

Plan:
– CBC Chemistry
– IVF @ 2.5 x Maintenance 15 ml/hr
– Heat Support – Check temperature Q two hours until 99 F

SURGERY:
Temporary waiver due to illness

Behavior:

Animal ID:
33937

Animal Name: Goldy
Age: 7 Years

Tag Number:
Breed: Domestic Short Hair

Gender: Female
Spayed / Neutered: No

Handler:
Observer:

Behavior Assessment Date:
7/13/2018

Retest Date:

Retest Reason:

Next Test Date:

KNOWN HISTORY:
Goldy was brought in as a stray, so we don’t have any behavioral history or tendencies in a home environment.

MEDICAL BEHAVIOR:
7/10/18 Observed Behavior – gentle

Cage Condition:
No change

Reaction to assessor:
Goldy remains neutral, lying down on his cage bedding during the approach.

Reaction when softly spoken to:
Goldy remains immobile in place with eyes slightly open.

Reaction to cage door opening:
Goldy doesn’t move from her bedding, relaxed ears and forward.

Reaction to touch:
Goldy accepts the touch, slowly leans in but remains crouched position with no energy to seek attention.

Reaction to being picked up:
Unable to perform do to medical condition.

ACTIVITY LEVEL:
Laid back

VOCAL:
Quiet

CHARACTER TYPE:
Calm

Sweet

BEHAVIOR DETERMINATION:
Average

Behavior Asilomar
H – Healthy

BEHAVIOR SUMMARY:
Goldy interacts with the observer, appreciates attention, is easy to handle and tolerates all petting. This cat is showing behavior appropriate for new or experienced cat parents.

Recommendations

Adoption Recommendations:

Comments:

Suitability With Children:

Other:
7/13/18 Average

Yard Size:

Overall Rating:

Passed For Rehoming:

Indemnity/Waiver:

Adoption Summary:

Color Match:

Profile/Activity Level: