SERENADE – 20751

MANHATTAN CENTER

Serenade 20751

Location: Manhattan

Intake Date: 2/15/18

Intake Type: Stray

Medical Behavior: Orange

Sex: Spayed Female

Age: 5 years

Original Location: 10456

 

Vet Consultations
Date
Reasons
Vet Notes
Vet
Date Resolved
17-Feb-2018

17-Feb-2018

L V T Notes: 10:37 AM

PCV 13%
T.S. 8.1g/dL

Simbadol bottle 64 0.5ml SQ at 10:05am
Onsior 0.35ml SQ

17-Feb-2018
17-Feb-2018
Progress Exam
Vet Notes: 8:41 AM

s/o. BAR, standing in kennel. Reported that she ate and drank the night before. Looks slightly lethargic.

HR- 228 T – 103. 7 R – 30, MM pink and wet

Incision site looks healthy with no signs of dis-c or infection.

Skin tent – normal

A: Hyperthermia – suspect possible bacterial infection related to the pyometra

P:
Reduce fluids to 15ml/hr
1) Continue on fluids but on 2 x maintenance rate
2) Clavamox susp 13.75mg/kg BID – 0.8cc for 14 days
VET 991493

16-Feb-2018
Blood Work Interpretation
Vet Notes: 4:38 PM

Post-op bloodwork performed

CBC:
Severe anemia – 12.5%
WBC 25.8, neutrophils 16.96, bands suspected, lymphs 7.33, monos 0.92
Plt 132

Chemistry:
Glu 188
Alb 2.1
Globs 5.3

ASSESSMENT: Severe anemia, inflammatory leukogram, thyrombocytopenia, hypoalbuminemia.

Pt is alert in kennel, ataxic, walking around, shivering, tachycardic.

Continue IVF at 25 ml/hr overnight. No antibiotics indicated.

Recheck PCV/TS tomorrow and full blood panel in 2 days.

1088
VET 991088

16-Feb-2018
Spay/Neuter Summary
Vet Notes: 4:40 PM

[Surgery Template – Cat Spay]

Was this cat in heat, pregnant or have a pyometra? Open Pyometra

Ventral Midline Incision was made half way between the pubic ridge and umbilicus 4 cm
Ovaries Ligated with the auto-ligation technique
Uterine Body Ligated with: a millers knot and a transfixation/circumfrential knot using 3-0 PDS
Abdominal Closure in a simple cont pattern using 3-0 PDS
Skin Sub Q closed continuously in a simple cont pattern for the sub-q layer and intradermal pattern for the skin with 3-0 PDS

Green Linear Tattoo Placed on Midline
Surgeon: 1493

Additional Comments: An addition hemostat clamp was placed at the uterine body prior to excision to ensure no leakage of the purulent material. The pyometra was confirmed by dissection.

Medical Assistant: 4:03 PM

Anesthesia Summary: Feline OHE

Pre Medication

Ketamine 100mg/mL injectable, 0.3 mL IM
Dexdomitor 0.5mg/mL injectable, 0.11 mL IM

Induction:
Butorphanol 10mg/mL injectable, 0.04 mL IM

Anesthesia Notes:

Size 4 fr. ET tube placed, maintained general anesthesia throughout procedure on isoflurane and O2. Used (non-rebreathing system with 0.5 L bag.
22 g IVC placed in RF cephalic vessel.

Intraoperative IV LRS at 5-10mL/kg/hr: 40 mL/hr

NSAID:
Robenacoxib (Onsior) 20mg/mL injectable, 0.35 mL, SQ, once, for post-operative pain relief. Given pre/post operatively.

Other
Simbadol 1.8mg/mL injectable, 0.5 mL SQ, once, for pain relief, given post-operatively.

Given Antisedan 5mg/ml –0.1 ml IM, once. at 4 PM.

Recovery
Uneventful

Anesthetist/Surgical Monitor (P#’s):
0391/1498

Start 0.5 cc simbadol 1.8 mg/ml sid x 4 days and 0.35 cc Robenacoxib 20 mg/ml sid x 2 days as pain management.
VET 991493

16-Feb-2018
Tech Exam
L V T Notes: 1:39 PM

Gave 0.11 mls SQ of Dexdomitor .5 mg/kg at 1:00pm for sedated rads of Abdomen = right lateral and VD. As per Dr. Anderson.
LVT-E 991390
16-Feb-2018
16-Feb-2018
Radiograph Review
Vet Notes: 1:32 PM

Possible pyometra- sedation for rads and exam

O: Sedated w/ 15mcg/kg dexdomitor. No HM ausuclted. Bradycardic d/t dexdomitor.

2-view AXR: uterus diffusely distended, rest of abdomen no abnormalities noted

A: Open pyometra

P: Surgery to spay this afternoon.
VET-P 991445
16-Feb-2018
16-Feb-2018
DVM Intake
Vet Notes: 11:13 AM

[DVM Intake]
DVM Intake Exam

Estimated age: approx. 5yo
Microchip noted on Intake? neg
Microchip Number (If Applicable):

History : stray, found to have discharge coming from rear end. Eating and drinking while here, normal temp.

Subjective: BAR. Growling, hissing. Pet was netted during LVT intake, and during DVM intake. Limited PE due to behavior. Moderate amount of purulent discharge noted on cage paper.

Observed Behavior –

Evidence of Cruelty seen – n

Evidence of Trauma seen – n

Objective

T =
P = wnl
R = wnl
BCS 5/9

EENT: Eyes clear, no nasal or ocular discharge noted
Oral Exam: did not assess
PLN: not assessed
H/L: NSR, NMA, Lungs clear, eupnic. Difficult to auscult due to growling, hissing, and being in net.
ABD: not assessed due to behavior and being in net.
U/G: Intact female. No vulvar discharge noted, but purulent discharge on cage paper.
MSI: Ambulatory x 4. Small amount of dried discharge around anal/vulvar area.
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal: normal externally

Assessment
possible pyometra (open?)

Prognosis: fair

Plan:
dexdomitor 15mcg/kg IM then take 2 view AXR to assess for possible pyometra.

SURGERY:
Okay for surgery
VET-P 991459

16-Feb-2018
LVT Intake
L V T Notes: 3:07 AM

[LVT Intake Exam]

Microchip Scan: negative, did not place
Evidence of Cruelty: no
Observed Behavior: hissing and growling, allowed handling via net, placed in feral den for comfort
Sex: intact female
Estimated Age: appx 5y+

Subjective: finder reported that animal had “leaking” from anus and inappetance, perianal area is wet but does not appear to be diarrhea, clear d/c from vagina, temp 100.5F
Eyes: clear
Ears: clean
Oral Exam: moderate staining, cat did not tolerate handling of head
Heart: WNL
Lungs: WNL
Abdomen: distended and fluid, non painful
Musculoskeletal: WNL BCS 5/9
Mentation: BARH

Preliminary Assessment: possible pyometra or other infection

Plan: DVM intake, in medical for observation

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