PILLOE – 11764
Gone - 11-6-2017 Manhattan
GONE 11/6/17—- 12 year old Pilloe was brought in as a stray. He is weak, dehydrated and lethargic and has an infected wound on his paw. He also has a heart murmur. He was started on antibiotics but needs more medical.
MANHATTAN CENTER
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
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