LANCASTER – A1107944
Safe - 4-13-2017 Staten Island
SAFE 4/13/17 – FIV POSITIVE – Lancaster came in as a stray and a very sweet boy! He is eating well since he first came in and needs a bit more TLC.
STATEN ISLAND CENTER
FIV POSITIVE
LANCASTER – A1107944
MALE, BLK TABBY, DOMESTIC SH MIX,3 yrs
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition ILLNESS Intake Date 04/04/2017, From NY 10309, DueOut Date 04/07/2017,
Medical Behavior Evaluation GREEN
Medical Summary DVM Intake Exam Findings History Subjective Observed Behavior – tolerated handling Evidence of Cruelty seen – no Evidence of Trauma seen – no Objective microchip scan negative BCS 5/9, temp 103.6 severely decreased skin turgor EENT: Eyes clear, AU- erythema, dry brown debris, severe nasal congestion and clear mucoid discharge Oral Exam: severe gingivitis PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, mildly increased effort ABD: Non painful, no masses palpated U/G: MI, 2 descended testicles MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat CNS: mentation appropriate – no signs of neurologic abnormalities Assessment: Approx 3 yo MI DSH elevated temp- R/O infection vs inflammation vs other nasal congestion and discharge- R/O URI vs other dehydrated severe gingivitis suspect ear mites Plan give 80 mls SQ LRS SID x 3 days give doxycycline 32 mg PO SID x 10 days do not give vaccines today due to elevated temp
4/4/17
DVM Intake Exam Findings
History
Subjective
Observed Behavior – tolerated handling
Evidence of Cruelty seen – no
Evidence of Trauma seen – no
Objective
microchip scan negative
BCS 5/9, temp 103.6
severely decreased skin turgor
EENT: Eyes clear, AU- erythema, dry brown debris, severe nasal congestion and clear mucoid discharge
Oral Exam: severe gingivitis
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, mildly increased effort
ABD: Non painful, no masses palpated
U/G: MI, 2 descended testicles
MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat
CNS: mentation appropriate – no signs of neurologic abnormalities
Assessment: Approx 3 yo MI DSH
elevated temp- R/O infection vs inflammation vs other
nasal congestion and discharge- R/O URI vs other
dehydrated
severe gingivitis
suspect ear mites
Plan
give 80 mls SQ LRS SID x 3 days
give doxycycline 32 mg PO SID x 10 days
do not give vaccines today due to elevated temp
4/6/17
Subjective
recheck URI; per ACS Lancaster was eating the dry food very quickly this morning and choking on it so it was removed; he then ate some wet food normally
Objective
decreased skin turgor
EENT: Eyes clear, AU- erythema, dry brown debris, severe nasal congestion and clear mucoid discharge
Oral Exam: mild/moderate dental calc and severe gingivitis; no oral ulcers seen
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, mildly increased effort
ABD: Non painful, no masses palpated, prominent kidneys bilaterally
U/G: MI, 2 descended testicles
MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat
CNS: mentation appropriate – no signs of neurologic abnormalities
Assessment: Approx 3 yo MI DSH
nasal congestion and discharge- R/O URI vs other
dehydrated
severe gingivitis
suspect ear mites
FIV positive
decreased appetite- improved today
Plan
applied Revolution today
continue doxycycline
continue SQ fluids as needed
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View all entries in: Safe Cats 2017-04