RINO – A1125136

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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