SAM – 31934

BROOKLYN CENTER

Sam 31934

Location: Brooklyn

Intake Date: 6/21/18

Intake Type: Owner Surrender

Medical Behavior: Green

Sex: Neutered

Age: 16 years

Original Location: 11234

Medical:

31934
Sam
Cat
Yes
Black
White
Male

Spayed / Neutered
Age
Primary Microchip #
Rabies Tag
Weight
Spay / Neuter Due Date
Temperature

Yes
16 Years

10 lbs 9.6 oz

Veterinary Clinic Software Record #:
Weight:   10 lbs 9.6 oz

Date of Weighing:   6/21/2018

Date Spayed / Neutered:
Schedule Surgery Date:

Stitches Removal Date:

Clinic Name:

Previously Spayed / Neutered:    Yes

General Vet Notes:

Previous Medical Details:

Known Allergies or Medical Conditions:

Feeding Requirements:

 

Indemnities/Waivers:

 

Medical Notes
Notes
Date
No Medical Notes Stored

Vet Treatments
Date Administered
Vet Treatment Type
Treatment Result
Administered by External Vet
6/21/2018
Re-weigh

6/21/2018
Gabapentin (100mg Capsule)

6/21/2018
Microchip Implantation

6/21/2018
Rabies

6/21/2018
Internal Parasite Treatment – Pyrantel

6/21/2018
Flea/Tick Treatment – Paradefense

6/21/2018
Fvr-Cp 1 Of 2

6/21/2018
FeLV/FIV Snap
Negative

Vet Treatments Due
Date Due
Vet Treatment Type
7/5/2018
Fvr-Cp 1 Of 2
7/5/2018
Internal Parasite Treatment – Pyrantel
7/5/2018
Re-weigh
7/21/2018
Flea/Tick Treatment – Paradefense
6/21/2019
Rabies

Medications
Medication
Amount Dispensed
Frequency
Date From
Date To
Doses Administered
Vet Name
Reason
Notes
Simbadol 1.8mg/ml
3 ml
0.6 mL SQ SQ every 1 day(s)
22-Jun-2018
26-Jun-2018
3
VET-P

Give 0.6 mL SQ until 6/26/18
Tresaderm
1 drops
1-2 drops in right ear, 2 times every 1 day(s)
22-Jun-2018
29-Jun-2018
4
VET

Apply 1-2 drops IN RIGHT EAR ONLY. Clean left ear externally with saline only.
Amoxicillin/Clavulanic Acid Drops 62.5 mg/ml
15.4 ml
1.1ml, 2 times every 1 day(s)
22-Jun-2018
29-Jun-2018
3
VET

Give 1.1ml by mouth twice a day

Drug Usage
No drugs administered to this animal.

Vet Consultations
Date
Reasons
Vet Notes
Vet
Date Resolved
24-Jun-2018
Progress Exam
Vet Notes: 1:08 PM

Progress exam

History : o/s 6/21. Reported to have a cyst on left ear, went to a vet, and was rx’d tresaderm. At BACC started on simbadol.
6/22-cleaned ears. Started on clavamox and tresaderm.

Subjective: BARH. A little nervous but allowed all handling. Good appetite. Normal BM and U in litter box.

Objective
P = wnl
R = wnl
BCS 6/9
EENT: AS has a fleshy mass at base of canal with purulent d/c, AD has moderate brown waxy debris, no nasal or ocular discharge noted
Oral Exam: oligodontia
PLN: No enlargements noted
H/L: Grade3/6 HM, RR, Lungs clear, eupneic
ABD: Non painful, no masses palpated
U/G: MN
MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat
CNS: Mentation appropriate – no signs of neurologic abnormalities

Assessment:
Geriatric
Grade 3/6 HM
Otitis AU
Mass at base of canal AS
Oligodontia

Prognosis: good

Plan:
Recommend NH placement- needs sedated otoscopic exam, biopsy of mass +/- CT of head
Continue clavamox until 6/29
Continue tresaderm until 6/29 (may need extension)
Continue simbadol until 6/26
Ok to move out of medical, recheck 6/26
Rec echocardiogram for HM
VET

23-Jun-2018
Progress Exam
Vet Notes: 2:28 PM

Vet check – recheck otitis/mass in ear

H: Intake on 6/21. Noted to have mass in ear with purulent discharge. Started on Simbadol

S/O: BARH. Excellent appetite. Clean litter at time of exam. Active in cage, allows all handling but appears skittish
EENT: Nuclear sclerosis OU, no ocular or nasal discharge, moderate dental tartar, mild gingivitis, mild otitis externa AD, AS – moderate otitis externa with slightly raised fleshy mass at ventral inner pinnae, purulent discharge with foul odor
HL: Grade IV/VI heart murmur, lungs auscult clear
ABD: Soft, non tender
INTEG: Full unkempt hair coat
MS: Ambulatory x 4
UG: Neutered

Assessment:
1) Mass (left ear canal)- r/o benign process (polyp) vs malignant
2) Otitis

Prognosis: fair to guarded, depending on what the mass is

Plan:
Continue with current treatment and monitoring plan
Recommend NH placement- needs sedated otoscopic exam, biopsy of mass +/- CT of head
VET

22-Jun-2018
Progress Exam
Vet Notes: 4:05 PM

H: Intake on 6/21. Noted to have mass in ear with purulent discharge. Started on Simbadol

S: BAR. Ate well. No eliminations in box. Nervous, but allows all handling.

CRT: <2s. Gums: pink, moist
Eyes: Grossly appropriate OU.
Ears: AS- Fleshy mass noted within pinna and obstructing majority of external canal, moderate purulent discharge noted in canal; AD- mild to moderate ceruminous debris
Nasal Cavity: No nasal discharge.
Oral Cavity: Mild to moderate dental tartar/periodontal disease
PLN: WNL
Heart: No murmurs or arrhythmias.
Lungs: Eupneic, lungs clear.
Abd: Soft, non-painful.
U/G: Normal external genitalia. No discharge.
Musculoskeletal: Ambulatory x 4 with no appreciable lameness.
BCS = 5/9
Integument: Otherwise unremarkable haircoat.
Neuro: Appropriate mentation.
Rectal: Not performed. Externally normal.

Assessment:
1) Mass (left ear canal)- r/o benign process (polyp) vs malignant
2) Otitis

Prognosis: fair to guarded, depending on what the mass is

Plan:
Cleaned AS with saline
Continue Simbadol until 6/26
Added Clavamox 13.75mg/kg PO BID x 7 days
Clean and evaluate AS daily
Added Tresaderm AD BID x 7 days
Recommend NH placement- needs sedated otoscopic exam, biopsy of mass +/- CT of head
VET

21-Jun-2018
DVM Intake
Vet Notes: 7:02 PM

[DVM Intake]
DVM Intake Exam

Estimated age: 16 yo
Microchip noted on Intake? neg
Microchip Number (If Applicable):

History : o/s. Reported to have a cyst on left ear, went to a vet, and was rx’d tresaderm

Subjective: BAR. Sweet and friendly. Well behaved during PE. Some resistance, growling, and vocalizing during med handling.

Observed Behavior –

Evidence of Cruelty seen – n

Evidence of Trauma seen – n

Objective

T =
P = wnl
R = wnl
BCS 6/9

EENT: AU otitis. AS bloody purulent malodorous discharge coming from canal. Painful, p would not further examination. Eyes clear, no nasal or ocular discharge noted
Oral Exam: missing most teeth. Right upper and lower canines still present.
PLN: No enlargements noted
H/L: Grade III/VI left systolic HM. NSR, CRT < 2, Lungs clear, eupnic
ABD: Soft, gaseous, Non painful, no masses palpated
U/G: MN
MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal: normal externally

Assessment:
Geriatric
HM
AU otitis
AS bloody purulent infection
Missing most teeth
Gaseous abdomen

Prognosis: good

Plan:
simbadol 0.6 mL SQ x 5 days
monitor in medical. Re-evaluate tomorrow to see if pet can be sedated for ear exam, cleaning, and treatment. If sedation is not recommended (due to age and HM), try to do after giving simbadol and gabapentin.

SURGERY:
Neutered
VET-P

Profile:

This behavior note was written by the previous owner of this pet. Animal Care Centers of NYC provides this as a guide for optimal pet placement.
Please use these notes in conjunction with the information provided by NYCACC.

Animal ID: 31934

Animal Name: Sam

Breed: Domestic Short Hair

This animal came from:
Giveaway
Spay/Neuter status
Yes
Is this cat having litter box issues?
No
Basic Information:
Sam is a 16 year old black and white neutered cat that was surrendered by his owner due to personal problems. The owner stated that someone gave Sam to her when he was 8 weeks old.
Previously lived with:
Owner
How is this cat around strangers?
Owner stated that when around strangers Sam is friendly and outgoing. When playing with adults he is gentle.
How is this cat around children?
Sam has not spent time in the home with children so it is unknown how he will react.
How is this cat around other cats?
Sam has not spent time in the home with other cats. so it is unknown how he will react.
How is this cat around dogs?
Sam has not spent time in the home with dogs so it is unknown how he will react.
Behavior Notes
Owner stated that overall same behaves well. On the way to the ACC in the car Sam was quiet. Sam is not bothered if he is bathed brushed or has his nails trimmed. He loves to be held and brushed. Sam isn’t bothered if he is put in a carrier or disturbed while he sleep.
Bite history:
Sam has no bite history.
Energy level/descriptors:
Medium
Has this cat ever had any medical issues?
Yes
Medical Notes
Sam has a cyst in his left ear.
For a New Family to Know
Owner described Sam as friendly affectionate and mellow. Sam likes to walk outside on a leash and loves affection. When at home he likes to sit in his owners lap. He has been kept indoors only and eats both wet and dry cat food. Sam is used to a hooded litter box with clumping or clay litter. Sam scratches on a post made out of rough rope.

Behavior Notes:

During intake Sam allowed the counselor to collar him and take his picture.

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