RANDY – A1103100
Safe - 2-10-2017 Brooklyn
*** SAFE 02/10/17 ***
15 YEARS OLD – OWNER DIED – EMACIATED, DENTAL DISEASE, HYPERTHYROID, NEEDS VET EVAL – CALM AND ALLOWS HANDLING – CAME IN WITH HOUSEMATES
Brooklyn Center
My name is RANDY. My Animal ID # is A1103100. – P
I am a neutered male orange and white domestic lh mix. The shelter thinks I am about 15 YEARS old.
I came in the shelter as a STRAY on 02/06/2017 from NY 11358, owner surrender reason stated was OWNER DIED. I came in with Group/Litter #K17-087921.
MOST RECENT MEDICAL INFORMATION AND WEIGHT
02/09/2017 Exam Type RE-EXAM – Medical Rating is 4 NC – SEVERE CONDITIONS NOT CONTAGIOUS, Behavior Rating is NONE, Weight 5.0 LBS.
02/09/17 Recheck exam. O: BARH. Eating/drinking well. mm=lt pink, moist. ORAL: No drooling, no oral bleeding. Mod calculus, missing teeth. EENT: Mild brown crusting medial canthus OU. No nasal discharge or sneezing. INTEG: Caudal half of body shaved. Matting on ventral chest. Skin turgor WNL. A: Improved hydration, appetite, overall condition. P: Finish LRS today. Continue eye meds, pain control. Buprenorphine out of stock, will switch to Simbadol 1.8 mg/ml 0.3 ml SQ q 24 hours x 3 days. Fair prognosis. 02/07/17 Monitor appetite, overall condition. O: QAR. Eating canned food well. ORAL: Mod. calculus, missing teeth. Small amount of drool dried on chin. Sensitive on oral exam. EENT: No nasal discharge, no sneezing. Mild brown crusting medial canthus OU, no active discharge or chemosis. MS: Amb x 4. Marked generalized muscle wasting (more evident now that he has been groomed). INTEG: Caudal half of body has been shaved to remove mats. Remaining haircoat dry, unkempt. A: Stable, with good appetite. Dehydration 5%, emaciated body condition. Dental disease with signs of oral pain. P: CBC/CHEM/T4 panel done. CBC: WBC 25.94 K/uL (2.87-17.02) MONO 1.31 K/uL (0.05-0.67) NEU 21.18 K/uL (1.48-10.29) HCT 25.1% (30.3-52.3) HGB 8.2 g/dL (9.8-16.2) Rest WNL. CHEM: All values WNL. T4: 1.5 ug/dL (0.8-4.7) Assessment: Mod. neutrophilic leukocytosis with monocytosis. R/o stress leukogram, secondary to dental/periodontal disease. Mild non-regenerative anemia – r/o anemia of chronic disease. Otherwise labs unremarkable, no signs of CRF or hyperthyroidism. Plan: Feed soft food only. Start Buprenorphine 0.3 mg/ml 0.15 ml SQ BID x 5 days. Erythromycin ointment OU BID x 7 days. Continue SQ LRS as planned. Rec. dental cleaning/extractions when in better overall physical condition. Prior to that, if seems to be losing weight or still not eating well, may need to be evaluated for other illness such as neooplasia. Fair prognosis with appropriate treament.
PET PROFILE MEMO
No Pet Profile Memo
WEB MEMO
No Web Memo
02/09/2017 BEHAVIOR EVALUATION – EXPNOCHILD
Exam Type BEHAVIOR
KNOWN HISTORY: Unknown Randy was brought in as a stray, so we cannot speak to his behavior in his previous home. EVALUATION: Cage Condition: Cat hiding under, cage rearranged, no change, recently cleaned, other Reaction to assessor: Randy was sitting in his litter box with his head lowered. Reaction when softly spoken to: Randy slow blinks then rises up and looks around the kennel for an exit. Reaction to cage door opening: Randy hisses and becomes alert. Reaction to touch: Randy lip licks, trembles and sinks low when the assessor extends his hand out. He hisses and whips around quickly when touched then quickly shifts away. His body is tense and he allows limited contact. ENRICHMENT NOTES: 02/07/17 Seemed startled when I opened the cage door, was at very back, lying down. When I slowly reached in he became very tense, hissed and turned to the rear corner of the cage, apparently attempting to flee. MEDICAL BEHAVIOR: Calm, a little fearful, allows all handling. ACTIVITY LEVEL: Laid back VOCAL: Quiet CHARACTER TYPE: Skittish RECOMMENDATIONS: _x_ Experienced, adult home only- Randy tolerates attention and petting but may be fearful or stressed in the shelter, and may be intimidated by small children. He may be a little more independent, and may need time to warm up to his new home. Due to the behaviors seen in the care center, we feel that this cat will do best in an experienced, adult only home who understands this cat may need time to warm up to his new home and family at his own pace.
GROUP BEHAVIOR EVALUATION
No Group Behavior Summary
02/06/2017 INITIAL PHYSICAL EXAM
Medical rating was 4 NC – SEVERE CONDITIONS NOT CONTAGIOUS, behavior rating was NONE
02/06/17 Microchip scan pos #985121003006114 MN, approx 15 yrs. O: QAR. mm=lt pink, tacky, CRT<2 s. Calm, a little fearful, allows all handling. ORAL: Gingivitis, mod. calculus, missing teeth. EENT: Iris atrophy and lenticular sclerosis OU. H/L: HR=180, RR=16. Lungs clear, no murmurs/arrhythmias. ABD/UG: palpation WNL. neutered male. MS: Emaciated BCS=2/9. Generalized muscle wasting. INTEG: Matted haircoat. A: Age est. 15 years. Mild dehydration 5-7%. Dental disease. Matted, emaciated body condition. DDx: metabolic disease, hyperthyroid, infectious disease, neoplasia, other. P: Scheduled for mat shave and CBC/CHEM/T4 panel. Start 50 ml LRS SQ q 24 hours x 3 days (change pending lab results). Further therapy pending lab results.
02/09/2017 RE-EXAM (LAST MAJOR EXAM)
Medical rating 4 NC – SEVERE CONDITIONS NOT CONTAGIOUS,
02/09/17 Recheck exam. O: BARH. Eating/drinking well. mm=lt pink, moist. ORAL: No drooling, no oral bleeding. Mod calculus, missing teeth. EENT: Mild brown crusting medial canthus OU. No nasal discharge or sneezing. INTEG: Caudal half of body shaved. Matting on ventral chest. Skin turgor WNL. A: Improved hydration, appetite, overall condition. P: Finish LRS today. Continue eye meds, pain control. Buprenorphine out of stock, will switch to Simbadol 1.8 mg/ml 0.3 ml SQ q 24 hours x 3 days. Fair prognosis. 02/07/17 Monitor appetite, overall condition. O: QAR. Eating canned food well. ORAL: Mod. calculus, missing teeth. Small amount of drool dried on chin. Sensitive on oral exam. EENT: No nasal discharge, no sneezing. Mild brown crusting medial canthus OU, no active discharge or chemosis. MS: Amb x 4. Marked generalized muscle wasting (more evident now that he has been groomed). INTEG: Caudal half of body has been shaved to remove mats. Remaining haircoat dry, unkempt. A: Stable, with good appetite. Dehydration 5%, emaciated body condition. Dental disease with signs of oral pain. P: CBC/CHEM/T4 panel done. CBC: WBC 25.94 K/uL (2.87-17.02) MONO 1.31 K/uL (0.05-0.67) NEU 21.18 K/uL (1.48-10.29) HCT 25.1% (30.3-52.3) HGB 8.2 g/dL (9.8-16.2) Rest WNL. CHEM: All values WNL. T4: 1.5 ug/dL (0.8-4.7) Assessment: Mod. neutrophilic leukocytosis with monocytosis. R/o stress leukogram, secondary to dental/periodontal disease. Mild non-regenerative anemia – r/o anemia of chronic disease. Otherwise labs unremarkable, no signs of CRF or hyperthyroidism. Plan: Feed soft food only. Start Buprenorphine 0.3 mg/ml 0.15 ml SQ BID x 5 days. Erythromycin ointment OU BID x 7 days. Continue SQ LRS as planned. Rec. dental cleaning/extractions when in better overall physical condition. Prior to that, if seems to be losing weight or still not eating well, may need to be evaluated for other illness such as neooplasia. Fair prognosis with appropriate treament.
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View all entries in: Safe Cats 2017-02