OREO – A1122640

Brooklyn Center

FIV POSITIVE

My name is OREO. My Animal ID # is A1122640. – P
I am a male white and black domestic sh mix. The shelter thinks I am about 6 YEARS old.

I came in the shelter as a STRAY on 08/20/2017 from NY 11225, owner surrender reason stated was STRAY.

08/22/2017 AT RISK MEMO
Oreo is at risk due to medical condition. Please see exam notes below.

MOST RECENT MEDICAL INFORMATION AND WEIGHT
08/22/2017 Exam Type RE-EXAM – Medical Rating is 4 C – SEVERE CONDITIONS , Behavior Rating is NONE, Weight 8.1 LBS.

Re-exam wound on neck and ear History : Intake 8/20-wound on ventral neck and mass in right ear. FIV+ S: BAR in cage and eating well. Purring and friendly during PE. ~5% dehydrated (prolonged skin tent) Objective P = wnl R = wnl BCS 3/9 EENT: no ocular d/c, AD- pink mass o`ccluding external ear canal- yellow purulent discharge, AS-mild waxy debris, no nasal discharge Oral Exam: Mild tartar, recession of gum line on upper canines, mm light pink, fractured canines PLN: wnl H/L: no sneezing or audible congestion ABD: Non painful, no masses palpated U/G: intact male, 2 testicles descended MSI: Ambulatory x 4, no live parasites noted, ~3cmx2cm wound with minimal purulent discharge noted on ventral neck with necrotic borders, cellulitis extending up to right ear to form possible draining tract, purulent material around base of right ear CNS: mentation appropriate – no signs of neurologic abnormalities Assessment: FIV + URI Conjunctivitis-improving Aural Mass- r/o polyp vs neoplasia vs other Wound ventral neck- r/o bite vs asbscess vs draining tract vs other Mild Anemia Infectious/inflammatory Leukogram Plan: Continue simbadol 0.24mg/kg SQ SID x2d Continue Onsior 2mg/kg SQ x2d Decided to hold off on wound treatment here due to inability to manage wound in the shelter. Rec placement in a hospital and a wound treatment ASAP Rec skull rads to look for bony involvement Continue Erythromycin Ophthalmic OU BID Continue LRS 150 ml SQ BID Continue Doxycycline 50 mg/ml – 0.75 ml PO SID Add Baytril 5mg/kg PO SID x10d Recheck daily Prognosis: Guarded- depending on response to medications and cause of draining tract

08/20/2017 PET PROFILE MEMO
08/20/17 10:37 Cat came in as a stray so history is unknown.

WEB MEMO
No Web Memo

BEHAVIOR EVALUATION
No Behavior Summary

GROUP BEHAVIOR EVALUATION
No Group Behavior Summary

08/20/2017 DVM INTAKE PHYSICAL EXAM
Medical rating was 4 C – SEVERE CONDITIONS , behavior rating was NONE
DVM Intake Exam Estimated age: approx 7-9 years Microchip noted on Intake? No History : Presents as stray. Friendly vocal, allows all handling with minimal restraint. BAR- approx 7% dehydrated Evidence of Cruelty seen – No Evidence of Trauma seen – Yes Objective P = 180 R = 42 BCS 4/9 EENT: Grey crusting discharge OU, OS- Clean, OD- pink mass occluding external ear canal- yellow purulent discharge, Clear nasal discharge Oral Exam: Mild tartar, recession of gum line on upper canines, mm light pink, tacky PLN: Enlarged right submandibular LN, left submandibular LN WNL H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: intact male MSI: Ambulatory x 4, Flea dirt – no live fleas seen, Wound with purulent discharge noted on ventral neck CNS: mentation appropriate – no signs of neurologic abnormalities Assessment: FIV + URI Conjunctivitis Aural Mass- r/o polyp vs neoplasia vs other Wound ventral neck- r/o bite vs asbscess vs other Mild Anemia Infectious Leukogram Plan: CBC / Chemistry / T4 Simbadol 0.48 ml SQ Clip and clean wound ventral neck- may need to be flushed and debrided surgically Erythromycin Ophthalmic OU BID x 10 days LRS 150 ml SQ Doxycycline 50 mg/ml – 0.75 ml PO SID x 10 days Blood Work Results: Alb 2.0 (2.3-3.9) ALKP 12 (14-111) Glob (5.9 (2.8-5.1) WBC 44.75 (2.87-17.02) Mono 1.78 (0.05-0.67) Neutrophils 36.96 (1.48-10.29) HCT 29.9 (30.3-52.3) Prognosis: Fair – depending on response to medications SURGERY: Temporary waiver due to URI and Wound

08/22/2017 RE-EXAM (LAST MAJOR EXAM)
Medical rating 4 C – SEVERE CONDITIONS ,
Re-exam wound on neck and ear History : Intake 8/20-wound on ventral neck and mass in right ear. FIV+ S: BAR in cage and eating well. Purring and friendly during PE. ~5% dehydrated (prolonged skin tent) Objective P = wnl R = wnl BCS 3/9 EENT: no ocular d/c, AD- pink mass o`ccluding external ear canal- yellow purulent discharge, AS-mild waxy debris, no nasal discharge Oral Exam: Mild tartar, recession of gum line on upper canines, mm light pink, fractured canines PLN: wnl H/L: no sneezing or audible congestion ABD: Non painful, no masses palpated U/G: intact male, 2 testicles descended MSI: Ambulatory x 4, no live parasites noted, ~3cmx2cm wound with minimal purulent discharge noted on ventral neck with necrotic borders, cellulitis extending up to right ear to form possible draining tract, purulent material around base of right ear CNS: mentation appropriate – no signs of neurologic abnormalities Assessment: FIV + URI Conjunctivitis-improving Aural Mass- r/o polyp vs neoplasia vs other Wound ventral neck- r/o bite vs asbscess vs draining tract vs other Mild Anemia Infectious/inflammatory Leukogram Plan: Continue simbadol 0.24mg/kg SQ SID x2d Continue Onsior 2mg/kg SQ x2d Decided to hold off on wound treatment here due to inability to manage wound in the shelter. Rec placement in a hospital and a wound treatment ASAP Rec skull rads to look for bony involvement Continue Erythromycin Ophthalmic OU BID Continue LRS 150 ml SQ BID Continue Doxycycline 50 mg/ml – 0.75 ml PO SID Add Baytril 5mg/kg PO SID x10d Recheck daily Prognosis: Guarded- depending on response to medications and cause of draining tract

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