SIMONE – A1115923
Safe - 6-27-2017 Manhattan Rescue: Hurricane Pets Rescue Please honor your pledges: http://hurricanepetsrescue.org/
***SAFE 06/27/17***BEGINNER ALERT! Sweet Simone is a 13 yr old senior who has diabetes. She came in as a stray – and has a small lip wound, a heart murmur which should be checked out, and needs dental care. She needs someone who will give her the vet care she needs to feel better.
Manhattan Center
*DIABETIC*
My name is SIMONE. My Animal ID # is A1115923. – P
I am a female brn tabby domestic lh mix. The shelter thinks I am about 13 YEARS old.
I came in the shelter as a STRAY on 06/20/2017 from NY 10457, owner surrender reason stated was STRAY.
06/23/2017 AT RISK MEMO
Simone A1115923 was placed At Risk for Medical Reasons- please see notes below
MOST RECENT MEDICAL INFORMATION AND WEIGHT
06/23/2017 Exam Type CAGE EXAM – Medical Rating is 4 NC – SEVERE CONDITIONS NOT CONTAGIOUS, Behavior Rating is NONE, Weight 5.8 LBS.
Hx: emaciated/dehydrated on intake; dx with diabetes and started on insulin (1U BID); severely matted-small laceration occurred during shavedown S/O: eating well interactive no discharge OU or nares mydriatic OU with opaque sclera matted fur H/L not asculted plantigrade stance 2/9 BCS A: DM matted heart murmur suspect partial retinal detachment vs cataracts vs other P: cwct
06/20/2017 PET PROFILE MEMO
Cat is tired and docile.
WEB MEMO
No Web Memo
06/23/2017 BEHAVIOR EVALUATION – BEGINNER
Exam Type BEHAVIOR
ACTIVITY LEVEL: Laid back VOCAL: Quiet CHARACTER TYPE: Calm, Sweet MEDICAL BEHAVIOR: 6/20/17- Subjective: Calm, sweet, allows all handling ENRICHMENT NOTES: 6/21/17- Dozing on bedding, woke and stood when spoken to. Came to the front when door opened, leaned and arched into pets, looked around. Moves very slowly. EVALUATION: Cage Condition: No change Reaction to assessor: Simone remains neutral, resting on her cage bedding. Reaction to door opening: Simone remains in place, relaxed body posture. Reaction to touch: Simone head bunts the assessor’s hand and appreciates petting on the head and body. Reaction to Being Picked up: Allows the pickup and remains neutral. BEHAVIOR SUMMARY: Beginner Simone is easy to handle and tolerates all petting. This cat can go to a beginner home.
GROUP BEHAVIOR EVALUATION
No Group Behavior Summary
06/20/2017 DVM INTAKE PHYSICAL EXAM
Medical rating was 4 NC – SEVERE CONDITIONS NOT CONTAGIOUS, behavior rating was NONE
DVM Intake Exam Estimated age: 10-15 years based on overall condition Microchip noted on Intake? Scanned negative History : Stray, no information given. Good appetite this morning. Assistant was shaving pt overnight and accidentally cut a small wound in the skin of the left thigh, caudal aspect. Subjective: Calm, sweet, allows all handling Observed Behavior – Sits in one place and allows handling Objective BCS 1-2/9, MMs pink EENT: Immature cataracts OU. Ears clean, no nasal discharge noted Oral Exam: Moderate tartar and gingivitis. Missing R maxillary canine tooth – lip entrapment causing mild wound on upper R lip adjacent to R mandibular canine tooth. PLN: No enlargements noted H/L: Grade 1-2/6 soft systolic heart murmur, PMI right base/parasternal. NSR. Lungs clear, eupnic. ABD: Tucked up, non painful, no masses palpated U/G: Female MSI: Entire body is heavily matted with mats very close to skin. Wound on left thigh, caudal aspect – mild serosanguinous discharge, some fur in the wound. Wound is 2-3 cm long x1 cm wide, minimal skin tension. No masses noted. CNS: mentation appropriate – no signs of neurologic abnormalities CBC/chemistry/T4 performed today: Glucose 490 mg/dl BUN 47 mg/dl – R/O pre-renal azotemia vs. early renal Creat 1.8 mg/dl (WNL) Alb 2.7 (WNL) Globs 6 g/dl – R/O dental disease vs. other location of infection GGT 8 U/L Na 167 mmol/L (elevated) – R/O dehydration T4 2.1 ug/dl (WNL) Hct 41.4% (WNL) WBC 19.49, neuts 16.83 K/ul – R/O infection Assessment: 1. Diabetes mellitus 2. Emaciated 3. Matted, small wound on left hind leg from clippers 4. Cataracts 5. Dental disease and missing teeth, small lip wound 6. Very soft but repeatable heart murmur Plan 1. LRS 250 ml SQ x5 days, consider IVC 2. Start ProZinc 1 unit BID 3. Needs thorough grooming, then re-cleaning of wound and closure (either suture or glue will work fine) 4. Recommend cardiac evaluation and dentistry in near-term future 5. Will need regular follow-up veterinary care Prognosis: Fair SURGERY: Temporary waiver due to: age and emaciation. 1088
06/23/2017 CAGE EXAM (LAST MAJOR EXAM)
Medical rating 4 NC – SEVERE CONDITIONS NOT CONTAGIOUS,
Hx: emaciated/dehydrated on intake; dx with diabetes and started on insulin (1U BID); severely matted-small laceration occurred during shavedown S/O: eating well interactive no discharge OU or nares mydriatic OU with opaque sclera matted fur H/L not asculted plantigrade stance 2/9 BCS A: DM matted heart murmur suspect partial retinal detachment vs cataracts vs other P: cwct
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