MULDER – A1091917

Manhattan Center

My name is MULDER. My Animal ID # is A1091917. – P
I am a male black domestic sh. The shelter thinks I am about 5 YEARS old.

I came in the shelter as a STRAY on 10/01/2016 from NY 11208, owner surrender reason stated was STRAY.

MOST RECENT MEDICAL INFORMATION AND WEIGHT
10/05/2016 Exam Type RE-EXAM – Medical Rating is 3 C – MAJOR CONDITIONS , Behavior Rating is NONE, Weight 7.9 LBS.

10/5/16 S: Pt very alert today, tense, allows limited exam. Could not examine mouth closely due to behavior – pt hissed and bit the tongue depressor I was using to lift his lips. O: BCS 4/9, MMs pink Dried discharge on right side of pt’s face, small pocket visible in right cheek Mild upper resp congestion, mild serous nasal discharge Tense abd Male intact A: 1. URI 2. Abscess R cheek – R/O tooth root abscess vs. traumatic wound vs. other cause 3. Neurological signs – appear to be resolving. R/O peripheral vestibular disease vs. head trauma vs. encephalitis vs. other P: Continue antibiotics (Convenia injection and doxycycline), re-evaluate tomorrow. May need to sedate to flush wound and evaluate inside of cheek. 1088 —- 10/04/16 18:13 much more alert today tried to flee does not seem neurologic still congested purulent d/c insid emouth from abcess but exterior improving 10/03/16 12:09 QAR obtunded behavior but seems to be better than at admission eyes wnl congested abcess right cheek draining eating well on his own test for fiv/felv fair/guarded prognosis 10/02/16 11:44 Initially dull and food untouched but when put food in front of him brightened up and started to eat very well Clear OU, no obvious nystagmus today, moderate brown debris AU, mucoid nasal discharge left nostri, congested OP minimal tartar, possible tooth root asbcess right side PLN wnl H/L reg, no obvious murmur, ssp, lungs clear/eupenic ABD snp MSK amb x 4 but weak Integ abscess right side of face with large amount of active bloody drainage, dirty coat BCS 3/9 UG m/i, s/s testes Neuro QAR, normal cranial nerves, no obvious nystagmus today, no obvious neck or back pain A:URI Abscess right face-r/o tooth root vs. trauma Underconditioned Otitis externa +/- neuro vs. weak P:Drained and cleaned abscess Cleaned with dilute chlorhexidine Convenia 8 mg/kg SQ given Start doxy PO x 10 days Need to help start eating but putting food infront of him, make sure he know where it is Prognosis guarded Otomax bid x 7 days 10/1/16: scanned negative sex:male-intact age:approximately 2 yrs BARH ear:ear dirty cleanned with ear solution eyes:discharged nose:seen discharge teeth:slightly staining and tartar possible uri swollen rt. jaw and head injury possible neurologic disease not eating aimless walking ear mites negative fleas negative allowed to handling during examin ambx4 NOSF

10/01/2016 PET PROFILE MEMO
10/01/16 14:15hrs Was able to pick up and put in carrier.

WEB MEMO
No Web Memo

10/04/2016 BEHAVIOR EVALUATION – AVERAGE
Exam Type BEHAVIOR
Mulder was brought in as a stray, so we cannot speak to his behavior in his previous home. His finder reports they were able to pick him up and place him into a carrier. He also allowed all handling during his initial medical exam. Please note that this cat is being treated for a medical condition at the time of evaluation. It is difficult to determine at this time how the medical condition may be affecting the behavior. Reaction to assessor: Mulder was resting upon approach. Reaction when softly spoken to: Mulder lifts his head up slightly, but doesn’t turn to look at the assessor. Reaction to cage door opening: Mulder remains soft and relaxed. Reaction to touch: Mulder remains in place and accepts petting all over his body. He closes his eyes and leans in slightly for cheek rubs. Reaction to being picked up: Mulder allows pick up and remains calm when held. Behavior Determination: Average Mulder interacts with the Assessor, appreciates attention, is easy to handle and tolerates all petting. This cat is showing behavior appropriate for new or experienced cat parents.

GROUP BEHAVIOR EVALUATION
No Group Behavior Summary

10/01/2016 INITIAL PHYSICAL EXAM
Medical rating was 4 NC – SEVERE CONDITIONS NOT CONTAGIOUS, behavior rating was NONE
scanned negative sex:male-intact age:approximately 2 yrs BARH ear:ear dirty cleanned with ear solution eyes:discharged nose:seen discharge teeth:slightly staining and tartar possible uri swollen rt. jaw and head injury possible neurologic disease not eating aimless walking ear mites negative fleas negative allowed to handling during examin ambx4 NOSF

10/05/2016 RE-EXAM (LAST MAJOR EXAM)
Medical rating 3 C – MAJOR CONDITIONS ,
10/5/16 S: Pt very alert today, tense, allows limited exam. Could not examine mouth closely due to behavior – pt hissed and bit the tongue depressor I was using to lift his lips. O: BCS 4/9, MMs pink Dried discharge on right side of pt’s face, small pocket visible in right cheek Mild upper resp congestion, mild serous nasal discharge Tense abd Male intact A: 1. URI 2. Abscess R cheek – R/O tooth root abscess vs. traumatic wound vs. other cause 3. Neurological signs – appear to be resolving. R/O peripheral vestibular disease vs. head trauma vs. encephalitis vs. other P: Continue antibiotics (Convenia injection and doxycycline), re-evaluate tomorrow. May need to sedate to flush wound and evaluate inside of cheek. 1088 —- 10/04/16 18:13 much more alert today tried to flee does not seem neurologic still congested purulent d/c insid emouth from abcess but exterior improving 10/03/16 12:09 QAR obtunded behavior but seems to be better than at admission eyes wnl congested abcess right cheek draining eating well on his own test for fiv/felv fair/guarded prognosis 10/02/16 11:44 Initially dull and food untouched but when put food in front of him brightened up and started to eat very well Clear OU, no obvious nystagmus today, moderate brown debris AU, mucoid nasal discharge left nostri, congested OP minimal tartar, possible tooth root asbcess right side PLN wnl H/L reg, no obvious murmur, ssp, lungs clear/eupenic ABD snp MSK amb x 4 but weak Integ abscess right side of face with large amount of active bloody drainage, dirty coat BCS 3/9 UG m/i, s/s testes Neuro QAR, normal cranial nerves, no obvious nystagmus today, no obvious neck or back pain A:URI Abscess right face-r/o tooth root vs. trauma Underconditioned Otitis externa +/- neuro vs. weak P:Drained and cleaned abscess Cleaned with dilute chlorhexidine Convenia 8 mg/kg SQ given Start doxy PO x 10 days Need to help start eating but putting food infront of him, make sure he know where it is Prognosis guarded Otomax bid x 7 days 10/1/16: scanned negative sex:male-intact age:approximately 2 yrs BARH ear:ear dirty cleanned with ear solution eyes:discharged nose:seen discharge teeth:slightly staining and tartar possible uri swollen rt. jaw and head injury possible neurologic disease not eating aimless walking ear mites negative fleas negative allowed to handling during examin ambx4 NOSF

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