RINO – A1125136
Gone - 9-13-2017 Manhattan
DIED 9/13/17— 10 year old Rino was surrendered for “cost”. Owner is unable to afford vet care. Rino seems to have pyometra and needs medical. Please help this older kitty get the care she needs!
MANHATTAN CENTER
RINO – A1125136
SPAYED FEMALE, GRAY, AMER SH MIX,10 yrs
OWNER SUR – STRAY WAIT, NO HOLD Reason COST
Intake condition ILLNESS Intake Date 09/11/2017, From NY 10002, DueOut Date 09/11/2017,
Medical Behavior Evaluation GREEN
Medical Summary DVM Intake Exam Estimated age: reported to be 10 years, age consistent with exam Microchip noted on Intake? History : owner surrender because owner is unable to afford care for suspected pyometra Subjective: QAR Observed Behavior – slightly lethargic, docile, allows handling Evidence of Cruelty seen – none Evidence of Trauma seen – none Objective BCS 4.5/9 EENT: OS-mildly increased epiphora; AU-clean, no nasal discharge Oral Exam: mm pale pk, tacky; moderate tartar/staining PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: soft, nonpainful; thickened tissue palpable, suspected uterus U/G: female intact; severe, bloody mucoid vulvular discharge MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat CNS: mentation appropriate – no signs of neurologic abnormalities Rectal: grossly normal Lateral abd rad: large fluid filled intra-abdominal soft tissue structure, suspected to be uterus Assessment Pyometra Plan CBC (not enough blood pre-op for chem) Place IVC, 50 ml bolus LRS then continued at 10 ml/hr Baytril 100 mg/ml: 0.3 ml IV SID Ampicillin 250 mg/ml: 0.3 ml IV TID, dose given pre-op Spay today Prognosis: fair to good SURGERY: Okay for surgery
Weight 6.9
Medical:
Blood work:
RBC 3.02 M/ul 5.0-10
HCT 13.8 % 30-45
HGB 4.2 g/dl 9.0-15.1
MCV 45.7 fL 41-58
MCH 13.9 pg 12-20
MCHC 30.4 g/dl 29.0-37.5
RDW 22.7 % 17.3-22
%RETIC 0.9 %
RETIC 26 K/uL 3.0-50.0
WBC 27.93 K/uL 5.5-19.5
%NEUT 1.4 %
%LYM 85.6 %
%MONO 12.6 %
%EOS 0.3 %
%BASO 0.1 %
NEUT 0.4 K/uL 2.5-12.5
LYM 23.9 K/uL 0.4-6.8
MONO 3.51 K/uL 0.15-1.7
EOS 0.08 K/uL 0.1-0.79
BASO 0.04 K/uL 0.00-0.10
PLT 3 K/uL 175-600
MPV 10.3 fl
PDW %
PCT 0 %
Parameters Results Reference Ranges
GLU 145 mg/dl 71-59
BUN 20 mg/dl 16-36
CREAT 0.5 mg/dl 0.8-2.4
BUN/Creat 40
PHOS 4.2 mg/dl 3.1-7.5
CA 7.2 mg/dl 7.8-11.3
TP 7.5 g/dl 5.7-8.9
ALB 2.1 g/dl 2.3-3.9
GLOB 5.4 g/dl 2.8-5.1
ALB/Glob 0.4
ALT 48 U/L 12-130
ALKP 10 U/L 14-111
GGT U/L 0-1
TBILI 1.6 mg/dl 0.0-0.9
CHOL 77 mg/dl 65-225
Na 149 mmol/L 150-165
K 4.7 mmol/L 3.5-5.8
Na/K 32
Cl 110 mmol/L 112-129
Osm calc 301 mmol/kg
Re-exam 9/12/17:
Hx: Pyometra – reported vulvar discharge for past 2-3 days. Spayed yesterday; uterus was engorged and lymphatics were very large. Pt very dehydrated, anemic (Hct 13%), elevated globulins and t. bili. IVF run at 10 ml/hr overnight. Baytril and ampicillin (TID) started yesterday pre-op. One dose Cerenia given yesterday. Pt did not eat overnight.
S: Alert, sitting in kennel, IVF connected but pump turned off. Allows all handling.
O: BAR, better hydration today, estimated 5% dehydrated based on tacky MMs. BCs 4.5/9, MMs pale pink and tacky
EENT: No discharge OU, nose.
H/L: NSR, NMA. Eupnic, quiet lung sounds.
Abd: Soft, no pain on palpation, no masses palpated
M/S/I: Amb x4. No skin lesions noted. Ventral abd incision from spay – no swelling, discharge, erythema.
UG: Female, spayed yesterday
Neuro: Alert and appropriate, no sign neurological deficiencies
A:
1. Pyometra – removed yesterday
2. Anemia – R/O anemia of chronic disease
3. Dehydration
4. Poor appetite
Short-term prognosis: Good
P:
1. Maintain IVF today – consider d/c-ing tomorrow
2. Continue Baytril and IV ampicillin today – switch to BID IM ampicillin tomorrow
3. Continue Cerenia, monitor appetite
DVM Exam 9/11/17:
Estimated age: reported to be 10 years, age consistent with exam
Microchip noted on Intake?
History : owner surrender because owner is unable to afford care for suspected pyometra
Subjective: QAR
Observed Behavior – slightly lethargic, docile, allows handling
Evidence of Cruelty seen – none
Evidence of Trauma seen – none
Objective
BCS 4.5/9
EENT: OS-mildly increased epiphora; AU-clean, no nasal discharge
Oral Exam: mm pale pk, tacky; moderate tartar/staining
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: soft, nonpainful; thickened tissue palpable, suspected uterus
U/G: female intact; severe, bloody mucoid vulvular discharge
MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat
CNS: mentation appropriate – no signs of neurologic abnormalities
Rectal: grossly normal
Lateral abd rad: large fluid filled intra-abdominal soft tissue structure, suspected to be uterus
Assessment
Pyometra
Plan
CBC (not enough blood pre-op for chem)
Place IVC, 50 ml bolus LRS then continued at 10 ml/hr
Baytril 100 mg/ml: 0.3 ml IV SID
Ampicillin 250 mg/ml: 0.3 ml IV TID, dose given pre-op
Spay today
Prognosis: fair to good
SURGERY: Okay for surgery
LVT Exam 9/11/17:
BAR
scan negative
mild dehydration
allows handling
female intact
10 yrs old reported
mod tartar
clean EEN
bloody purulent vaginal d/c
poss pyometra
will place NPO sign if need sx
BCS 5/9
NOSF
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