SEBASTIAN – 29235
Safe - 6-15-2018 Manhattan Rescue: Animalkind Please honor your pledges: http://animalkindny.org/donate-index-impact
SAFE 6/15/18 Sebastian came to us as a stray and is a sweet older boy. He came in on the thin side possibly from being on the street for quite some time. He has been tested and negative for FeLv and FIV. – Please see additional blood work below.
SEBASTIAN is an 8-10 year old kitty who was brought in with mild hypothermia. He is dehydrated and needs follow up vet care including dental. Please help this senior kitty today.
MANHATTAN CENTER
Sebastian 29235
Location: Manhattan
Intake Date: 5/25/18
Intake Type: Stray
Medical Behavior: Blue
Sex: Male
Age: 8Years
Original Location: 10027
Vet Consultations
Date
Reasons
Vet Notes
Vet
Date Resolved
2-Jun-2018
Progress Exam
Vet Notes: 4:17 PM
SO
QAR. Sleeping a lot in kennel today.
currently on 5ml/hr RS IV fluids (maintenance).
Heart murmur ausculted
eating well
increased skin tent — suspect secondary to geriatric age
A
geriatric
underweight / emaciated
heart murmur
dental disease
P
continue LRS IV fluids 5ml/hr .
continue to monitor overall health while in shelter
VET 991516
1-Jun-2018
Tech Exam
L V T Notes: 2:32 PM
IVC replaced as per Rounds DVM. 20G IVC placed LFL. Returned to continued IVF.
LVT 991415
1-Jun-2018
31-May-2018
Progress Exam
Vet Notes: 5:48 PM
[DVM Intake]
DVM Intake Exam
Estimated age: 8
QAR – good appetite. Greeting DVM in kennel. No diarrhea noted in kennel
Objective
T = –
P = 200
R = wnl
BCS
Still 3-5% Dehydrated
EENT: Eyes clear, ears clean, no nasal or ocular discharge noted
PLN: No enlargements noted
H/L: NSR, grade 2/5 systolic heart murmur, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal: externally normal
Assessment
– as per previous exam
– QAR – eating and drinking
– Still 3-5% dehydrated but improved since intake
– no signs of diarrhea in kennel
Prognosis: Fair to good
Plan:
1) Increase fluids to 1.5 x maintenance
2) Place on TID feeding
VET 991493
30-May-2018
29-May-2018
Progress Exam
Vet Notes: 8:53 PM
Hx: Emaciated, dehydrated, mild heart murmur, dental disease. CBC/chem – mild neutrophilia (14 k/ul), no other abnormalities. Fecal float was negative. Pt was dewormed and is receiving IVF and probiotics.
Good appetite for dry food today.
S: Purring, very friendly today!
O: BAR, estimated 5% dehydrated, MMs pink
EENT: No nasal or ocular discharge
H/L: Grade 2/6 systolic heart murmur, NSR. Eupnic, no coughing or sneezing.
Abd: Full, not distended, not painful
M/S/I: Amb x4, no skin lesions noted
A:
1. Dehydration – not resolved
2. Heart murmur
P:
1. Increase IVF from 5 ml/hr to 8 ml/hr (did today at 4pm when this exam was performed)
2. Praziquantel 0.4 ml SQ
1088
VET 991088
28-May-2018
Progress Exam
Vet Notes: 9:37 AM
SO
BAR, very friendly and seeks attention in kennel.
currently on 5ml/hr LRS IV fluids (maintenance).
Heart murmur auscults the same as 5/27.
Actively eating well in kennel
A
dehydration <5%
geriatric
underweight / emaciated
heart murmur – r/o iatrogenic vs physiologic vs anatomic
dental disease
P
continue LRS IV fluids 5%.
continue to monitor overall healthy while in shelter
VET 991516
27-May-2018
Tech Exam
L V T Notes: 12:55 PM
Gross examination of feces: Paste-like texture. Grey with Red tint. No ova or parasites seen on microscopic evaluation.
LVT-E 991215
27-May-2018
27-May-2018
Progress Exam
Vet Notes: 9:27 AM
SO
BAR in kennel. Allowed all handling but did bite when DVM approached with 2nd hand. Allowed all handling after bite. Now on DOH hold. Underweight; dehydrated. Noted to have malodorous gray stool. Was on 15ml/hr LRS IV fluids overnight.
Eating well in kennel.
No coughing or sneezing. No nasal or ocular discharge.
Dental calculus 3/5; fractured canines.
Grade 3/6 parasternal murmur ausculated; lung sounds are clear.
Prolonged skin tent; eyes slightly sunken in orbits (both possible due to emaciated and geriatric state vs dehydration)
A
dehydration ~5%
geriatric
underweight / emaciated
heart murmur – r/o iatrogenic vs physiologic vs anatomic
dental disease
P
decrease LRS fluids to 5ml/hr
monitor heart murmur and overall condition in shelter.
VET 991516
26-May-2018
Blood Work Interpretation
Vet Notes: 6:51 PM
CbC
Mild Leukocystosis (17) with a mild neutrophilia (14) – inflammation vs infection
Chemistry
Unremarkable
A – Unremarkable
P – Monitor
VET 991493
26-May-2018
Tech Exam
L V T Notes: 4:41 PM
Placed 22g IVC LFL. IVF initiated @ 15mls/hr for 24 hours. Heat support provided with forced air rigged to housing.
LVT 991415
26-May-2018
26-May-2018
DVM Intake
Vet Notes: 3:48 PM
[DVM Intake]
DVM Intake Exam
Estimated age: 10
Microchip noted on Intake? n
Microchip Number (If Applicable): n
History: Stray
Subjective: QAR, odorous clay colored soft stool in litter box
Observed Behavior – timid, needed restraint
Evidence of Cruelty seen – n
Evidence of Trauma seen -n
Objective
T = 98
P = 160
R = wnl
BCS = 3/9
Prolonged skin tent – 5%
EENT: Eyes clear, mild Otitis externa, no nasal or ocular discharge noted
Oral Exam: fractured canines 1-4, 204 no pulp cavity, dental disease
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G: Two descended testicles
MSI: unkempt hair coat, diffuse alopecia/reduced hair coverage over dosum, flank and abdomen Ambulatory x 4, skin free of parasites, no masses noted
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal: soft stool on hind end
Assessment
– 5% dehydrated
– Mild hyperthermia
– thin hair coat/alopecia
– fractured canines (no pulp cavity exposure)
– loose odorous stool
– Mild otitis externa
Prognosis: Fair
Plan:
1) Place on fluids 2 x maintenance for 24 hrs and reassess
2) Give intake txs which include a dewormer
3) CBC/Chem/t4
4) Fecal float – requested for an LVT 5/27/2018
5) Provide heat support
6) Probiotics SID for 5 days
7) Tresaderm AU BID for 7 days
SURGERY:
Permanent waiver due to age and condition
VET 991493
26-May-2018
LVT Intake
L V T Notes: 6:07 AM
[LVT Intake Exam]
Microchip Scan: negative, placed 985113001883151
Evidence of Cruelty: no
Observed Behavior: allows all handling, affectionate and vocal
Sex: intact male
Estimated Age: appx 8y
Subjective: stray, no history, haircoat is short as if shaved or hair shafts were damaged, underweight, dirty haircoat
Eyes: clear
Ears: clean
Oral Exam: moderate to heavy staining
Heart: WNL
Lungs: WNL
Abdomen: WNL
Musculoskeletal: underweight, 3/9 BCS
Mentation: BAR, dehydrated
Preliminary Assessment: underweight, dehydrated, abnormal haircoat
Plan: DVM intake, DTM pulled, 50ml LRS SQ
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