JAKE – A1091479

Brooklyn Center

Jake A1091479, Stray, Spayed, 14 Years Old, Gray DLH, 3.8 lbs

Medical::

9/28/16

Recheck exam

O: QARH. mm=lt pink, moist. All food eaten overnight. Urine on towel.

EENT: No oculonasal discharge.

H/L: Lungs clear, no murmurs.

MS/Neuro: Was resting curled up on towel when approached. Assisted to stand but still unable to hold herself up, falls to the right. Non-ambulatory.

Integ: Matted fur, urine soaked in perineal fur. Small maggots visible on perineal fur.

A: Neurologic condition unchanged. Dermatitis/pyoderma with maggots now appearing.

P: Shave mats, remove maggots, clean skin with chlorhexidene solution.

Guarded prognosis.

9/27/16

Cat possibly hit by car.

Microchip scan neg.

O: QAR. Fearful and flinches away from touch, but able to handle.

Oral: No teeth.

EENT: Crusting at nares, mild congestion. Left pinna tipped.

H/L: No murmurs. Lungs clear.

ABD: Palpation WNL.

UG: Female.

MS: Emaciated body condition. Unable to stand, falls over when held up. No fractures or luxations palpable.

NEURO: Appears ataxic and has head tremors when trying to ambulate. Pos. withdrawal and nociception all 4 limbs. Visual OU, no nystagmus.

INTEG: Severely matted, dirty haircoat with leaves and other debris stuck. Erythema, moisture on perinuem, eythema and scabbing on tail. No maggots seen.

A: Approx. age 14 years. Emaciated – DDX: malnutrition, metabolic disease, hyperthyroid, inability to eat due to neuro problems, absence of teeth.

Neurologic disease Ddx: Vestibular disease (though would expect nystagmus), cerebellar disease, CNS trauma, infection, or inflammation, metabolic disease.

Matting due to inability to groom with secondary dermatitis, superficial pyoderma.

P: Start Amoxi-Clav 45.7 mg/ml. 0.5 ml PO BID x 10 days.

Offered canned food – ate enthusiastically. Continue to offer soft food only, TID feedings.

Shave mats tomorrow – try without sedation due to condition.

Guarded prognosis due to severity of neurologic symptoms – if does not improve within 48-72 hours, rec. EHR. If cat does improve, then rec. placement and further workup/treatment as indicated.

Enrichment::

09/28/16

Really small old guy in really rough shape, matted. Wobbly, head trembles. Flinches when try to touch. Devoured his food. Will check in on him after he’s been shaved.

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