LITTLE ONE – 29726
Safe - 6-7-2018 Brooklyn Rescue: Feline Rescue of SI Please honor your pledges: http://felinerescueofstatenisland.org/donation/
SAFE 6/7/18 **Our Cute LITTLE ONE NEEDS FOLLOW UP VET CARE! Echocardiogram & Anemia Work-Up ASAP!**(XRAYS & BLOODWORK ATTACHED )LITTLE ONE is 10 years old and was found on someone’s porch where he sat trembling for 3 days. He is unable to put weight on his hind legs and needs xrays to see what is wrong. He does have a heart murmur and dental issues. Little one would love to have a real home where he can get some follow up care and TLC.
BROOKLYN CENTER
Little One 29726
Care Center Location: Brooklyn
ZIP Code From: 11204
Intake Type: Stray
Medical Behavior: Blue
Age: 10 years
Sex: Neutered male
Weight: 8 lbs
INTAKE INFO:
This animal came from:Found StrayOrigin AddressIf yes, Please elaborate:Unknown information
Basic Information:Little One is a grey tabby and white cat that was found on someones porch and was brought to the ACC as stray.
Previously lived with:Unknown information
How is this cat around strangers?When meeting the staff at the ACC for the first time Little One was fearful but he allowed the counselor to pet and pick him up with no prlbems.
How is this cat around children?Unknown information
How is this cat around other cats?Unknown information
How is this cat around dogs?Unknown information
Behavior NotesUnknown information
Bite history:Unknown information
Energy level/descriptors:Unknown information
Medical NotesUnknown information
For a New Family to KnowUnknown information
Behavior Notes:During intake little One allowed the counselor to collar him and take his photo with no problems.
BEHAVIOR:
KNOWN HISTORY:
Litte One was brought into our care center as a stray so we have no previous history available.
MEDICAL BEHAVIOR:
05/31/18
Observed Behavior -nervous, allows exam.
ENRICHMENT NOTES:
05/31/18
Cage rearranged. Hiding behind the litter box, completely flat. Pupils partially dilated. Seems unsure and is wary of his surroundings. Body starts to shake when approached. Sniffs hand and accepts gentle petting on cheeks. Needs time to adjust.
Cage Condition:
Cage is slightly re-arranged
Reaction to assessor:
Little One is crouched in back of his kennel with a tense body and face as the kennel door opens.
Reaction when softly spoken to:
Little One tilts his ears and looks around the room when spoken to softly.
Reaction to cage door opening:
Little One licks his lips as the cage door opens.
Reaction to touch:
Little One tolerates slow and gentle petting while watching the assessor’s hand reach forward. He leans away and licks his lips with further interaction, then shifts his weight.
ACTIVITY LEVEL:
Mellow
VOCAL:
Quiet
CHARACTER TYPE:
Skittish
Independent
POTENTIAL CHALLENGES:
Fearful
Potential challenges comments:
Little One has displayed fearful behavior during their stay in the care center and has displayed distance-increasing behavior with extended handling. Fear aggression can occur when a cat perceives a threat and may escalate if they cannot escape. A fearful cat will feel more relaxed when given options, so provide him with the chance to move closer, investigate, or interact with you. Be sure to offer incentive such as treats or play time whenever the cat makes a small positive step. Please speak to an adoption counselor for additional information on methods to desensitize your cat to their fear stimulus.
BEHAVIOR DETERMINATION:
Experienced, adult only
Behavior Asilomar
TM – Treatable-Manageable
RECOMMENDATIONS:
None
BEHAVIOR SUMMARY:
Little One tolerates attention and petting but may be fearful or stressed in the shelter, and may be intimidated by small children. He may be a little more independent, and may need time to warm up to his new home.
Due to the behaviors seen in the care center, we feel that this cat will do best in an experienced, adult only home.
MEDICAL:
29726
Little One
Cat
Yes
Gray Tabby
White
Male
Spayed / Neutered
Age
Primary Microchip #
Rabies Tag
Weight
Spay / Neuter Due Date
Temperature
Yes
10 Years
985113001883617
8 lbs
Veterinary Clinic Software Record #:
Weight: 8 lbs
Date of Weighing: 5/31/2018
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
5/31/2018
Re-weigh
5/31/2018
Gabapenth (50 Mg/Ml)
5/31/2018
Microchip Implantation
5/31/2018
Rabies
5/31/2018
Internal Parasite Treatment – Pyrantel
5/31/2018
Fvr-Cp 1 Of 2
5/31/2018
Flea/Tick Treatment – Paradefense
5/31/2018
FeLV/FIV Snap
Negative
Vet Treatments Due
Date Due
Vet Treatment Type
6/14/2018
Fvr-Cp 1 Of 2
6/14/2018
Internal Parasite Treatment – Pyrantel
6/14/2018
Re-weigh
7/1/2018
Flea/Tick Treatment – Paradefense
5/31/2019
Rabies
Medications
Medication
Amount Dispensed
Frequency
Date From
Date To
Doses Administered
Vet Name
Reason
Notes
Fluids – LRS SQ
210 ml
70mls every 1 day(s)
1-Jun-2018
3-Jun-2018
3
VET 991524
Give 70mls SQ once a day. PLEASE DO IN PM SINCE FLUIDS WERE GIVEN AT 6PM ON 6/2/18
Cerenia (Maropitant) INJ 10 mg/ML
1.08 ml
0.36ml every 1 day(s)
1-Jun-2018
3-Jun-2018
3
VET 991524
Give 0.36ml SQ once a day. PLEASE GIVE THE CERENIA DOSE IN PM WITH THE FLUIDS AS 6/2/18 DOSE WAS GIVEN AT 6PM
Gabapentin 50 mg/ML
0 ml
1.6, 2 times every 1 day(s)
3-Jun-2018
6-Jun-2018
2
VET 991416
Give 1.6ml PO BID
Drug Usage
No drugs administered to this animal.
Vet Consultations
Date
Reasons
Vet Notes
Vet
Date Resolved
4-Jun-2018
Progress Exam
Vet Notes: 12:29 PM
Progress exam
History :stray intake 5/31-paraparesis, dental disease, and HM. Found weak outside. BG 140. Two view Pelvic radiographs- no overt fractures noted
Thoracic radiograph (VD only)- mild to moderate bronchial pattern noted.
6/1: Started on LRS and cerenia
PCV: 22% TS: 7.8
Chemistry: unremarkable
6/3-started gabapentin for anxiety
6/2:
CBC: Hct 14.4, non-regenerative (Retic 8K), Mild leukocytosis (18.9K) with neutrophilia (12.7K) and mild monocytosis (0.74)
T4: 1.5
PCV- 20%
Subjective: BARH. Was friendlier today and walked around normally. Good appetite. Normal BM and U. No murmur ausculted today. Has a low crouched walk and is very nervous but no neuro deficits noted.
Objective:
P =wnl
R =wnl
BCS 4/9
EENT: Eyes clear, ears clean, no nasal or ocular discharge noted
Oral Exam: severe dental disease
PLN: No enlargements noted
H/L: RR, NMA, Lungs clear, eupneic
ABD: Non painful, no masses palpated
U/G: MN
MSI: Ambulatory x 4 with crouched walk, trembling once out of the cage with excessive handling, skin free of parasites, no masses noted, healthy hair coat
CNS: Mentation appropriate – no signs of neurologic abnormalities
Assessment:
Geriactric, suspect underlying illness
Severe Dental Disease
Hx intermittent Grade 2/6 Heart Murmur- r/o underlying heart disease (HCM) vs physiologic (DRVOTO, anemia)-NOT AUSCULTED TODAY
Paraparesis/trembling- r/o anxiety vs neuropathy (IVDD, neoplasia, inflammatory/infectious meningitis) vs orthopedic vs metabolic
Anemia r/o non-regenerative (anemia of chronic disease, neoplasia)
Prognosis: Fair
Plan:
Continue gabapentin 20mg/kg PO BID until 6/6
Rec repeat PCV/TS tomorrow +/- start doxycycline to r/o mycoplasma
Rec echocardiogram for HM if persists
Rec workup for anemia
Stable and ok to move out of medical
VET 991416
3-Jun-2018
Progress Exam
Vet Notes: 11:42 AM
Progress exam
History :stray intake 5/31-paraparesis, dental disease, and HM. Found weak outside. BG 140. Two view Pelvic radiographs- no overt fractures noted
Thoracic radiograph (VD only)- mild to moderate bronchial pattern noted.
6/1: Started on LRS and cerenia
PCV: 22% TS: 7.8
Chemistry: unremarkable
6/2:
CBC: Hct 14.4, non-regenerative (Retic 8K), Mild leukocytosis (18.9K) with neutrophilia (12.7K) and mild monocytosis (0.74)
T4: 1.5
PCV- 20%
Subjective: BARH. Eating baby food and kitten food well. Normal U in litter box. Trembling but very nervous. Walks hunched down but cannot rule out due to nervousness as well.
Objective:
P =wnl
R =wnl
BCS 4/9
EENT: Eyes clear, ears clean, no nasal or ocular discharge noted
Oral Exam: severe dental disease
PLN: No enlargements noted
H/L: RR, Grade 2/6 heart murmur, Lungs clear, eupneic
ABD: Non painful, no masses palpated
U/G: MN
MSI: Ambulatory x 4 with crouched walk, trembling, skin free of parasites, no masses noted, healthy hair coat
CNS: Mentation appropriate – no signs of neurologic abnormalities
Assessment:
Geriactric, suspect underlying illness
Severe Dental Disease
Grade 2/6 Heart Murmur- r/o underlying heart disease (HCM) vs physiologic (DRVOTO, anemia)
Paraparesis/trembling- r/o anxiety vs neuropathy (IVDD, neoplasia, inflammatory/infectious meningitis) vs orthopedic vs metabolic
Anemia r/o non-regenerative (anemia of chronic disease, neoplasia)
Prognosis: Fair
Plan:
Last day of LRS and cerenia
Start gabapentin 20mg/kg PO BID x3d until 6/6
Rec repeat PCV/TS in 2 days +/- start doxycycline to r/o mycoplasma
Rec echocardiogram for HM
Rec workup for anemia
VET 991416
2-Jun-2018
2-Jun-2018
Progress Exam
Vet Notes: 3:56 PM
H: Intake on 5/31. Finder notes that he has not moved from her front porch in 3 days.
Two view Pelvic radiographs- no overt fractures noted
Thoracic radiograph (VD only)- mild to moderate bronchial pattern noted
6/1- Bloodwork
CBC: Hct 8% (was from blood from yesterday, suspect error as PLT are also low at 9),
PCV: 22%
Chemistry: unremarkable
Down for repeat CBC and T4 today
S: QAR. <5% dehydrated. Ate food from this morning. No urine or BM in cage. Very nervous/trembling
P wnl
R wnl
O: CRT: <2s. Gums: pale pink, tacky
Eyes: Grossly appropriate OU.
Ears: Unremarkable AU.
Nasal Cavity: No nasal discharge.
Oral Cavity: Severe tartar/periodontal disease
PLN: WNL
Heart: Grade II murmur ausculted. Pulses thready bilaterally
Lungs: Eupneic, lungs clear. No crackles or wheezes bilaterally.
Abd: Soft, non-painful. No palpable masses. No organomegaly appreciated.
U/G: Neutered male. No discharge.
Musculoskeletal: Ambulatory x 4, but crouches when walking and occasionally back legs splay out. No overt fractures or pain elicited on palpation.
BCS = 4/9
Integument: Otherwise unremarkable haircoat.
Neuro: Appropriate mentation.
Rectal: Not performed. Externally normal.
CBC: Hct 14.4, non-regenerative (Retic 8K), Mild leukocytosis (18.9K) with neutrophilia (12.7K) and mild monocytosis (0.74)
T4: 1.5
PCV- 20
Assessment
1) Geriactric, suspect underlying illness
2) Dental Disease, severe
3) Heart Murmur- r/o underlying heart disease (HCM) vs physiologic (DRVOTO, anemia)
4) Hindlimb weakness, no overt fractures identified- r/o neuropathy (IVDD, neoplasia, inflammatory/infectious meningitis) vs orthopedic (OA) vs other LMN disease (myasthenia gravis, toxin) vs thromboembolic disease (partial thrombus?) vs secondary to #5
5) Anemia, non-regenerative – r/o anemia of chronic disease vs neoplasia
Prognosis: Guarded to poor
Plan:
Continue LRS 20ml/kg SID x 3 days, then reassess on 6/3
Continue Cerenia 1 mg/kg SQ SID x 3 days, then reassess on 6/3
Due to quieter mentation and weakness of unknown cause, recommend holding on gabapentin for now in order to better monitor condition
Monitor condition closely- mentation, heart rate, pulses
VET 991524
1-Jun-2018
LVT-E 990081
1-Jun-2018
1-Jun-2018
Blood Work Interpretation
Vet Notes: 4:45 PM
cbc: HCT 8.6. HB 3.4 low mcv, mch high hchc
will confirm these numbers with manual
pcv
PCV: 22%
TS 7.8
chemistry unremarkable
VET-P 991027
1-Jun-2018
1-Jun-2018
Progress Exam
Blood Work Interpretation
Vet Notes: 1:13 PM
H: Intake on 5/31. Finder notes that he has not moved from her front porch in 3 days.
Two view Pelvic radiographs- no overt fractures noted
Thoracic radiograph (VD only)- mild to moderate bronchial pattern noted
Plan for Bloodwork today
S: QAR. ~5-6% dehydrated. NI in food. No urine or BM in cage. Very nervous/trembling
T 102F
P 260bpm
R 24bpm
O: CRT: <2s. Gums: pink, tacky
Eyes: Grossly appropriate OU.
Ears: Unremarkable AU.
Nasal Cavity: No nasal discharge.
Oral Cavity: Severe tartar/periodontal disease
PLN: WNL
Heart: Grade II murmur ausculted. Pulses thready bilaterally
Lungs: Eupneic, lungs clear. No crackles or wheezes bilaterally.
Abd: Soft, non-painful. No palpable masses. No organomegaly appreciated.
U/G: Neutered male. No discharge.
Musculoskeletal: Ambulatory x 4, but crouches when walking and occasionally back legs splay out. No overt fractures or pain elicited on palpation.
BCS = 4/9
Integument: Otherwise unremarkable haircoat.
Neuro: Appropriate mentation. CP WNL x4. Menace response and palpebral reflex WNL OU.
Rectal: Not performed. Externally normal.
CBC: Hct 8% (was from blood from yesterday, suspect error as PLT are also low at 9),
PCV: 22%
Chemistry: unremarkable
Assessment
1) Geriactric, suspect underlying illness
2) Dental Disease, severe
3) Heart Murmur- r/o underlying heart disease (HCM) vs physiologic (DRVOTO, anemia)
4) Hindlimb weakness, no overt fractures identified- r/o neuropathy (IVDD, neoplasia, inflammatory/infectious meningitis) vs orthopedic (OA) vs metabolic (hypokalemia, hypocalcemia, diabetes) vs other LMN disease (myasthenia gravis, toxin)
5) Anemia (not sure if regenerative or non-regenerative) – r/o regenerative (infectious, immune-mediated, hemorrhage less likely) vs non-regenerative (anemia of chronic disease, neoplasia)
Plan:
Start LRS 20ml/kg SID x 3 days, then reassess
Start Cerenia 1 mg/kg SQ SID x 3 days, then reassess
Due to quieter mentation and weakness of unknown cause, recommend holding on gabapentin for now in order to better monitor condition
Repeat CBC + T4 scheduled for tomorrow
VET 991524
31-May-2018
Radiograph Review
Vet Notes: 1:06 PM
no significant findings on cxr, axr
VET-P 991027
31-May-2018
DVM Intake
Vet Notes: 12:44 PM
[DVM Intake]
DVM Intake Exam
Estimated age:10 years
Microchip noted on Intake?n
Microchip Number (If Applicable):
History :stray. o stated on porch trembling in same place for 3 days
Subjective:reluctant to place weight on rear legs, walks low to ground, leg slide out on table. BG 140
Observed Behavior -nervous, allows exam
Evidence of Cruelty seen -n
Evidence of Trauma seen -n
Objective
T =
P =220
R =wnl
BCS 4/9
EENT: Eyes clear, ears clean, no nasal or ocular discharge noted
Oral Exam:severe dental disease with excessive tartar
PLN: No enlargements noted
H/L: NSR, 3/6 heart murmur, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G:neutered male
MSI: Ambulatory weak on back legs, skin free of parasites, no masses noted, healthy hair coat
CNS: Mentation appropriate – no signs of neurologic abnormalities
Assessment: lame, severe dental disease, heart murmur
Prognosis:fair
Plan:
chest and pelvic rads
cbc/chem/t4
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