JAVA – 33934

Medical:

33934
Java
Cat
Yes
Orange Tabby
None
Male

Spayed / Neutered
Age
Primary Microchip #
Rabies Tag
Weight
Spay / Neuter Due Date
Temperature

No
10 Years

7 lbs 15.68 oz

98.5 °F

Veterinary Clinic Software Record #:
Weight:   7 lbs 15.68 oz

Incoming Agency:
Date of Weighing:   7/10/2018

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:

Medical Notes
Notes
Date
No Medical Notes Stored

Vet Treatments
Date Administered
Vet Treatment Type
Treatment Result
Administered by External Vet
7/10/2018
Re-weigh

7/10/2018
Rabies

7/10/2018
Microchip Implantation

7/10/2018
Internal Parasite Treatment – Pyrantel

7/10/2018
Fvr-Cp 1 Of 2

7/10/2018
Flea/Tick Treatment – Paradefense

7/10/2018
FeLV/FIV Snap
Negative

7/10/2018
Flea/Tick Application – Capstar

Vet Treatments Due
Date Due
Vet Treatment Type
7/24/2018
Fvr-Cp 1 Of 2
7/24/2018
Internal Parasite Treatment – Pyrantel
7/24/2018
Re-weigh
8/10/2018
Flea/Tick Treatment – Paradefense
7/10/2019
Rabies

Medications
Medication
Amount Dispensed
Frequency
Date From
Date To
Doses Administered
Vet Name
Reason
Notes
Amoxicillin/Clavulanic Acid Drops 62.5 mg/ml
0 ml
0.7ml PO, 2 times every 1 day(s)
10-Jul-2018
After 20 occurrences
2
VET-P 991027

0.7ml po
Doxycycline Suspension 50 Mg/ml
0 ml
0.8 every 1 day(s)
11-Jul-2018
21-Jul-2018
1
VET 991416

Give 0.8ml PO SID
Gabapentin 50 mg/ML
0 ml
1.4, 2 times every 1 day(s)
11-Jul-2018
Discontinued 12-Jul-2018: Cancelled
1
VET 991416

Give 1.4ml PO BID

Drug Usage
No drugs administered to this animal.

Vet Consultations
Date
Reasons
Vet Notes
Vet
Date Resolved
12-Jul-2018

12-Jul-2018
Progress Exam
Blood Work Interpretation
Vet Notes: 9:07 AM

Progress exam

History: stray intake 7/10-fleas, hypothermic (96.8F on intake, 98.5F at 4pm), anemic. Given capstar, paradefense, heat support, and started on clavamox.
CBC: severe non-regenerative anemia 19.1 (30.3-52.3), severe leukocytosis 40.53 (2.87-17.02) with neutrophilia 29.1 (1.48-10.29), monocytosis 1.02 (0.05-0.67), severe eosinophilia 8.2 (0.17-1.57), severe basophilia 0.65 (0.01-0.26)
Chem: mild elevation BUN 46 (16-26) with normal creatinine, mild hypernatremia 168 (150-165), mild hyperglobulinemia 5.2 (2.8-5.1)
T4-wnl (1.2)
7/11-started on doxycycline and gabapentin

Subjective: BARH. No csvd. Noraml U, no BM. Great appetite. Very friendly and purring-no need for gabapentin to continue.

Objective
T =98.4 F
P =wnl
R =wnl
BCS 4/9
EENT: no ocular or nasal d/c, ears have mild brown waxy debris
Oral Exam: oligodontia, moderate to severe dental disease, pale but moist mm
PLN: No enlargements noted
H/L: NSR, gallop rhythm, CRT < 2, Lungs clear, eupneic
ABD: Non painful, no masses palpated
U/G: MI, 2 testicles descended
MSI: Ambulatory x 4, diffuse scabby alopecia with lichenification, no live fleas or flea dirt, no masses noted
CNS: Mentation appropriate – no signs of neurologic abnormalities

Assessment:
Severe non-regenerative anemia r/o immune mediated vs early blood loss (fleas)
Severe leukocytosis r/o infection vs inflammation vs neoplasia
Severe eosinophilia r/o parasites vs allergies vs neoplasia vs infectious
Severe basophilia r/o infectious vs neoplasia vs parasites
Dental disease
Geriatric

Prognosis: Fair to poor longterm prognosis

Plan:
Continue clavamox until 7/20
Continue doxycycline 10mg/kg PO SID until 7/21
D/c gabapentin
Temperature-98.4F
PCV/TS -20%/8 (stable, mildly improved)
Recheck BW 7/18, will likely need AUS and anemia workup
Rec echocardiogram for gallop rhythm
VET 991416

11-Jul-2018

11-Jul-2018
Progress Exam
Vet Notes: 1:49 PM

Progress exam

History: stray intake 7/10-fleas, hypothermic (96.8F on intake, 98.5F at 4pm), anemic. Given capstar, paradefense, heat support, and started on clavamox.
CBC: severe non-regenerative anemia 19.1 (30.3-52.3), severe leukocytosis 40.53 (2.87-17.02) with neutrophilia 29.1 (1.48-10.29), monocytosis 1.02 (0.05-0.67), severe eosinophilia 8.2 (0.17-1.57), severe basophilia 0.65 (0.01-0.26)
Chem: mild elevation BUN 46 (16-26) with normal creatinine, mild hypernatremia 168 (150-165), mild hyperglobulinemia 5.2 (2.8-5.1)
T4-wnl (1.2)

Subjective: BARH. No csvd. Eating well on own. No csvd. Friendly and was head butting and purring. Discussed with behavior team and rec extending gabapentin.

Objective
T =98.9F
P =wnl
R =wnl
BCS 4/9
EENT: nuclear sclerosis OU, no ocular or nasal d/c, ears have mild brown waxy debris
Oral Exam: oligodontia, moderate to severe dental disease, pale but moist mm
PLN: No enlargements noted
H/L: NSR, gallop rhythm, CRT < 2, Lungs clear, eupneic
ABD: Non painful, no masses palpated, mildly distended
U/G: MI, 2 testicles descended
MSI: Ambulatory x 4, diffuse scabby alopecia with lichenification, no live fleas or flea dirt
CNS: Mentation appropriate – no signs of neurologic abnormalities

Assessment:
Severe non-regenerative anemia r/o immune mediated vs early blood loss (fleas)
Severe leukocytosis r/o infection vs inflammation vs neoplasia
Severe eosinophilia r/o parasites vs allergies vs neoplasia vs infectious
Severe basophilia r/o infectious vs neoplasia vs parasites
Dental disease
Geriatric

Prognosis: Fair to poor longterm prognosis

Plan:
Continue clavamox until 7/20
Start doxycycline 10mg/kg PO SID x10d until 7/21
Start gabapentin 20mg/kg PO BID x7d until 7/18, reassess
CTM in VS, recheck temp tomorrow
Recheck BW in 1 week, will likely need AUS and anemia workup
VET 991416

10-Jul-2018
Progress Exam
Vet Notes: 3:58 PM

98.5 temp.
QAR

10-Jul-2018
DVM Intake
Vet Notes: 12:21 PM

[DVM Intake]
DVM Intake Exam

Estimated age:10
Microchip noted on Intake?n
Microchip Number (If Applicable):

History :stray

Subjective:severe flea infestation, hypothermic, good appetite, drooling. notable lack of secondary sex characteristics for 10 year old male tom.

Observed Behavior -hissing but allows exam

Evidence of Cruelty seen -n

Evidence of Trauma seen -n

Objective

T =96.8
P =200
R =wnl
BCS 4/9

EENT: aging chnages to eyes
Oral Exam:oligodontia, tongue dark discolored, ptyalism
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G:2 testis
MSI: Ambulatory x 4, severe fleas fad, moist dermatitis in places
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal:
blood work: hct 19% moderate BUN elevation, normal creat, increased eos, leukocytosis
Assessment: fad, anemia, dental disease, hypothermia.

Prognosis:fair

Plan:capstar, paradefense, clavamox 0.7ml bid x 10d, heat support

SURGERY:

Permanent waiver due to age
VET-P 991027

10-Jul-2018
Spay-Neuter Waiver Documentation
Vet Notes: 11:39 AM

[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.

Intake Behavior:

Date:

Upon intake Java had a sick posture and was also underweight. When coming out of crate he seems a little shy. Java also has fleas but he was receptive to handling. He stood still for his intake photo and allowed us to collar him.