GRAY – 14780

Brooklyn Center

Gray 14780, 14 Years Old, Gray Tabby DSH, Spayed, 5 lbs, Stray 11/27/17

Medical:

28-Nov-2017
Progress Exam
Blood Work Interpretation
Vet Notes: 10:46 AM

Progress exam
History: Intake 11/27. Give SQ LRS.
Subjective: QAR, ~6-7% dehydrated. Not eating. No c/s/v/d. Ataxic and overall poor condition.
Objective
P = WNL
R = WNL
BCS 1/5
EENT: Eyes clear, ears clean, no nasal or ocular discharge noted
Oral Exam: Severe dental disease
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic
ABD: Non painful, no masses palpated, doughy
U/G: FS, no MGTs, no vulvar d/c
MSI: Ambulatory x 4, ataxic, skin free of parasites, no masses noted
CNS: Mentation appropriate, ataxic
Assessment:
Severe azotemia r/o Severe CKD
Geriatric
Underweight
Severe dental disease
Heart murmur-not appreciated today
Mild hypothermia- r/o secondary to cold temperatures outside and poor BCS
Anemia
Hyperproteinemia with hyperglobulinemia
Severe hyperphosphatemia
Prognosis: Guarded
Plan:
LRS 50ml SQ BID x3d until 11/30
CBC -mild lymphopenia 0.45 (0.92-6.88), mild neutrophilia 12.25 (1.48-10.29), eosinopenia 0.04 (0.17-1.57), anemia 22.7 (30.3-52.2), thrombocytopenia 114 (151-600)
Chem-Severe azotemia BUN >130 (16-36) creatinine 12 (0.8-2.4), hyperproteinemia 9.6 (5.7-8.9) with hyperglobulinemia 6.7 (2.8-5.1), sevre hyperphosphatemia >16.1 (3.1-7.5)
T4 low normal 0.9 (0.8-4.7)
Hold on vaccines for now
Monitor daily in medical
Rec hospitalization with IVC and IVF @ 100ml/kg/day (adjusted accordingly)
Rec full internal medicine workup
VET

27-Nov-2017
DVM Intake
Vet Notes: 7:14 PM
DVM Intake Exam
Estimated age: ~14 yr
Microchip noted on Intake? No
History : Found in someone’s yard today
Subjective:
Observed Behavior – Weak, did not like mouth being touched but fine for rest of exam
Evidence of Cruelty seen – No
Evidence of Trauma seen – No
Objective
T = 97.5
P = 200bpm
R = WNL
BCS 1/5
EENT: Eyes clear, ears clean, no nasal or ocular discharge noted
Oral Exam: Severe tartar
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G: FS, mammary tissue not developed
MSI: Ambulatory x 4, weak and legs slip laterally on metal table, skin free of parasites, no masses noted, some hair is matted, declawed on front paws, long back paws
CNS: Mentation appropriate – no signs of neurologic abnormalities
Assessment:
Geriatric
Underweight
Severe dental disease
Heart murmur
Mild hypothermia- r/o secondary to cold temperatures outside and poor BCS
Prognosis: Poor to fair pending additional dx and response to tx
Plan:
SQ fluids
microchip
flea treatment
pyrantel
Hold on vaccines for now
Keep in medical tonight, recheck tomorrow morning full blds in house including thyroid tomorrow (machines not working tonight- need to be recalibrated?)
SURGERY: NA since already spayed

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