PILLOE – 11764

DVM Intake Exam

Estimated age: approx. 12 yo
Microchip noted on Intake? 4622014916

History : Stray

Subjective: QAR, depressed but still minimally responsive. Weak, lethargic, can barely stand or move.

Observed Behavior –

Evidence of Cruelty seen – n

Evidence of Trauma seen – n

Objective

T =
P = wnl
R = eup
BCS 2/9

MM pale and dry, sunken OU, permanent skin turgor, 10% dehydrated
EENT: OD : ocular changes, difficult to assess due to sunken eye and raised TEL, cornea appears cloudy. Ears clear, no nasal or ocular discharge noted.
Oral Exam: mild to mod dental disease, no oral lesions
PLN: No enlargements noted
H/L: NSR, Grade III to IV/VI left systolic HM, CRT > 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated, doughy intestines
U/G: MN
MSI: Ambulatory x 4 but weak and could barely stand. RF : megapaw, moist wound with some purulent discharge on lateral aspect of metacarpal pad. No overt parasites seen, no masses noted, dry dirty unkempt hair coat, emaciated and severely muscle wasted.
CNS: depressed mentation, OD negative menace or PLR
Rectal: normal externally

Assessment:
severely medically compromised geriatric MN DSH
severe dehydration
lethargy
depressed mentation
OD ocular changes and negative menace/PLR
heart murmur — r/o secondary to dehydration vs underlying cardiac disease
RF megapaw and wound
emaciated/muscle wasted

Prognosis: poor

Plan:
LRS SQ 100mL
Simbadol 0.24mg/kg SQ once

Overnight medical to:
place IVC
start LRS @ 10ml/hr (~90ml/kg/day. Conservative due to HM)
start ampicillin 22mg/kg IV q8hr