MONET – 22951

Staten Island Center

Monet, 22951, 6 years Old, Black/White DSH, Female, 3 lbs, Stray 3/16/18

 

Medical:

 

 

Vet Consultations
Date
Reasons
Vet Notes
Vet
Date Resolved
16-Mar-2018
Progress Exam
Vet Notes: 11:42 AM

Subjective:

recheck exam

Objective

BCS 2/9

EENT: OU-crusted green discharge, crusted nasal discharge and congestion
Oral Exam: pale pink mm’s; mild/moderate dental calc
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic
ABD: Non painful, no masses palpated
U/G: Female; no vaginal discharge seen today
MSI: Ambulatory x 4, skin free of parasites, no masses noted, dirty haircoat, decreased skin turgor
CNS: Mentation appropriate – no signs of neurologic abnormalities

Assessment
emaciated
nasal and ocular discharge- R/O URI vs other
purulent vaginal discharge seen on initial exam, none today- R/O pyometra vs wound vs other

Plan:
cleaned eyes and nose
continue SQ fluids, erythromycin
VET 991385

15-Mar-2018
DVM Intake
Vet Notes: 11:39 AM

[DVM Intake]
DVM Intake Exam

Estimated age: 6 years
Microchip noted on Intake? scan negative

History : stray

Subjective:

Observed Behavior – trying to flee, hissing

Evidence of Cruelty seen – no

Evidence of Trauma seen – no

Objective

T = 101.9
BCS 2/9

EENT: OU-crusted green discharge, crusted nasal discharge and congestion
Oral Exam: pale pink mm’s; mild/moderate dental calc
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic
ABD: Non painful, no masses palpated
U/G: Female; purulent vaginal discharge
MSI: Ambulatory x 4, skin free of parasites, no masses noted, dirty haircoat, severely decreased skin turgor
CNS: Mentation appropriate – no signs of neurologic abnormalities

Assessment
emaciated
nasal and ocular discharge- R/O URI vs other
purulent vaginal discharge- R/O pyometra vs wound vs other

Prognosis: guarded

Plan:
gave convenia injection SQ (x)
start erythromycin OU BID x 7 days
start LRS 50 mls SQ SID
eating well
CBC/chemistry

recommend transfer for further diagnostics/treatment; recommend euthanasia if declining

SURGERY:
Temporary waiver due to URI, emaciated
VET 991385

15-Mar-2018
Blood Work Interpretation
Vet Notes: 6:00 PM

CBC:
mild anemia (hematocrit= 24.7)- R/O chronic disease vs Gi blood loss vs renal disease vs other
neutrophilia- R/O infection vs inflammation vs other
decreased platelets- R/O clumping vs causes of thrombocytopenia

Chemistry:
mild hyperglycemia (BG= 178)- R/O stress (most likely) vs DM
increased BUN- R/O dehydration vs renal disease vs other
hyperphosphatemia- R/O renal disease vs other
hyperglobulinemia- R/O chronic infection vs inflammation vs neoplasia vs other

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