JERRY – 8872
Safe - 10-11-2017 Brooklyn
SAFE 10/11/17 We are Siamese if you please- JERRY needs some follow up vet care @ BACC
Brooklyn Center
Jerry 8872– 6 years old, Male, Chocolate Point, Stray
Medical:
10/7/17
Vet Notes: 1:17 PM
Re-exam dehydration/ears
History : stray intake 10/6-otitis media and dehydration. Started on tresaderm and given LRS SQ once.
10/6
CBC-leukocytosis 24.5 (2.87-17.02), monocytosis 0.7 (0.05-0.67), neutrophilia 18.46 (1.48-10.29), eosinophilia 2.25 (0.17-1.57), anemia 24.3% (30.3-52.3)
Chem-elevated GGT 8 (0-4)
T4 normal 1.8
Subjective: QAR, ~6% dehydrated. Eating well but lethargic. Left head tilt and dehydrated. Urine in litter box but no bm.
Objective
EENT: Eyes clear no d/c, no nasal discharge noted. AS-severe purulent d/c, AD wnl
Oral Exam: severe dental disease
PLN: No enlargements noted
H/L: No c/s
ABD: Non painful, no masses palpated
U/G: MI
MSI: Ambulatory x 4, no masses noted, flea dirt but no live fleas, no masses
CNS: mentation appropriate – slight left side head tilt. CN wnl.
Assessment
Otitis media AS-severe with head tilt
Dehydrated
Fleas
Dental disease
Lethargic
Leukocytosis
Elevated GGT
Plan:
Monitor daily
Continue tresaderm AU BID (rec baytril otic but not available at BACC)
Start baytril 5mg/kg PO SID x14d
LRS 20ml/kg SID x5d
Capstar PO once
Fair to poor prognosis
10/6/17
Vet Notes: 11:36 AM
[DVM Intake]
Estimated age: 6 years
Microchip noted on Intake? n
History : stray
Subjective: QAR, 10% dehydrated
Observed Behavior – allowed all handling
Evidence of Cruelty seen -n
Evidence of Trauma seen -n
Objective
T =
P = 188
R = 24
BCS= 3/9
EENT: Eyes clear, no nasal discharge noted. Ears – AS – sever moist dark debrie and slight erythemia, mal odor
Oral Exam: sever plaque and tartar to upper left arcade
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G: both testicles palpable
MSI: Ambulatory x 4, no masses noted, flea dirt
CNS: mentation appropriate – slight left side head tilt
Rectal:
Assessment – otitis externa AS, PDDZ IV/IV, R/O causes for dehydration
Prognosis: guarded
Plan: CBC/CHEM/T-4, NaCl – 100ml SQ, Cleaned AS and applied Tresaderm.
SURGERY:
Temporary waiver due to dehydration
Enrichment:
10/05/17 Lying in back of kennel, tail wrapped around body. Avoids eye contact. Tolerates petting along head and body while becoming tense and turning his head to watch my hand, whites of eyes showing. Needs more time to adjust. Sprayed feliway.
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View all entries in: SAFE Cats 2017-10