LOU – 25069

Brooklyn Center

Lou 25069– 7 years old, Neutered, Domestic Short Hair, Gray Tabby, Stray, 4 pounds, Intake: 4/12/18

Animal ID
Name
Type
Mixed
Color(1)
Color(2)
Gender

25069
Lou
Cat
Yes
Gray Tabby
White
Male

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

Yes
14 Years

4 lbs 11.84 oz

97.9 °F

Veterinary Clinic Software Record #:
Weight:   4 lbs 11.84 oz

Date of Weighing:   4/12/2018

Date Spayed / Neutered:
Schedule Surgery Date:

Stitches Removal Date:

Clinic Name:

Previously Spayed / Neutered:    Yes

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
4/12/2018
FeLV/FIV Snap
Negative

Vet Treatments Due
Date Due
Vet Treatment Type
No Vet Treatments due for this animal.

Medications
Medication
Amount Dispensed
Frequency
Date From
Date To
Doses Administered
Vet Name
Notes
No medications administered to this animal.

Drug Usage
No drugs administered to this animal.

Vet Consultations
Date
Reasons
Vet Notes
Vet
Date Resolved
13-Apr-2018
Progress Exam
Vet Notes: 9:02 AM

Recheck condition – geriatric, severe anemia and neutrophilia

S/O: QAR. ~8% dehydration. Very weak but appears attention seeking and seems to appreciate petting. No interest in food or water. No eliminations overnight.
EENT: Pale/slightly grey mm, moderate dental staining, eyes clear, no ocular or nasal discharge, ears clean
HL: Normal thoracic auscultation
ABD: Normal abdominal palpation
INTEG: Full coat
MS: Unable to stand up on own and lies down immediately when propped up, no obvious injuries or palpable fractures
NEURO: Head bobbing but appears mentally appropriate — appears to be due to weakness

A: Geriatric, SEVERE anemia (unknown origin), moderate to marked neutrophilia; dehydration, weakness

P: Continue with fluid therapy. Rec 3pm deadline due to severity of condition.

Will require blood transfusion and supportive care. Poor prognosis
VET 990844

12-Apr-2018
Progress Exam
Vet Notes: 6:58 PM

recheck of pet 6:57 pm.
pt is sternal, able to eat on own, although with weakness and head tremors

rectal temp 97.9

rec push deadline back to 6 pm 4/13/18
vet check tomorrow am

12-Apr-2018
DVM Intake
Vet Notes: 2:34 PM

DVM Intake Exam

Estimated age: 8
Microchip noted on Intake?none

History : stray

Subjective:stray

Observed Behavior – obtunded

Evidence of Cruelty seen – none

Evidence of Trauma seen -none

Objective obtunded, somewhat responsive to touch stimulus, mm pale and tacky

T =95.4
P = 140
R = WNL
BCS 2/9

EENT: Eyes enophthalmia OU, ears clean, no nasal or ocular discharge noted
Oral Exam:
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated, atrophied intestines? no ingesta or feces, abdominal organs feel atrophied, nails overgrown and clean
U/G: kidneys round, palpate normally,neutered
MSI: BCS 2/9 skin free of parasites, no masses noted, rough haircoat
CNS: dull
Rectal: not performed

Assessment
starvation, sepsis
anemia, neutophilia

Prognosis: grave

Plan:
nail trim
IV catheter 24 gauge left cephalic, bolused 50 ml LRS, then set on micro drip: 1 drop every 3 seconds
syringe ed cat food gravy
Baytril 2.5 mg/kg IV
CBC/CHEM: Neuts 34,000 HCT 3%
alerted NH, pet needs blood transfusion for critical state, then would need intensive nursing care
if no rescue by 6 pm, rec EHR due to critical status, poor prognosis

Vet Notes: 2:34 PM

DVM Intake Exam

Estimated age: 8
Microchip noted on Intake?none

History : stray

Subjective:stray

Observed Behavior – obtunded

Evidence of Cruelty seen – none

Evidence of Trauma seen -none

Objective obtunded, somewhat responsive to touch stimulus, mm pale and tacky

T =95.4
P = 140
R = WNL
BCS 2/9

EENT: Eyes enophthalmia OU, ears clean, no nasal or ocular discharge noted
Oral Exam:
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated, atrophied intestines? no ingesta or feces, abdominal organs feel atrophied, nails overgrown and clean
U/G: kidneys round, palpate normally,neutered
MSI: BCS 2/9 skin free of parasites, no masses noted, rough haircoat
CNS: dull
Rectal: not performed

Assessment
starvation, sepsis
anemia, neutophilia

Prognosis: grave

Plan:
nail trim
IV catheter 24 gauge left cephalic, bolused 50 ml LRS, then set on micro drip: 1 drop every 3 seconds
syringe ed cat food gravy
Baytril 2.5 mg/kg IV
CBC/CHEM: Neuts 34,000 HCT 3%
alerted NH, pet needs blood transfusion for critical state, then would need intensive nursing care
if no rescue by 6 pm, rec EHR due to critical status, poor prognosis

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