SOFRITA – 20641

MANHATTAN CENTER

Sofrita 20641

Care Center Location: Manhattan

ZIP Code From: 10011

Intake Type: Owner surrender

Medical Behavior: Blue

Age: 7 years

Sex: Spayed female

Weight: 4 lbs 12.8 oz

 

KNOWN HISTORY:
Sofrita was brought in as a stray, so we don’t have any behavioral history or tendencies in a home environment.
MEDICAL BEHAVIOR:
2/13/18 Observed Behavior -quiet, cries
ENRICHMENT NOTES:
2/14/18
Severely emaciated. Curled up at back, eyes dilated, tense. Started whining quietly when door opened. Hissed when offered treats, hissed again when touched. Continued to lay in place, tolerated pets, started lip licking.

2/15/18
Curled up asleep at back, woke and became alert when spoken to, lifted head, eyes dilated. Lay in place when door opened, hissed, then started eating offered treats. Tolerated pets while eating, intermittent hissing. Allowed, slightly leaned into pets when done, slowly came forward for more treats after door closed, still some hissing. Seems very anxious.

2/18/18
Crouched on bedding towards back, eyes dilated, alert. Still seems a little anxious with room noise. Hissed when door first opened, then started eating treats, warmed up immensely. Leaned into pets, purred! Lured forward with more treats, then retreated and crouched again on bedding when done. Would do better in a quieter room.

2/19/18
Resting on bedding towards back, soft eyes and body. Lay in place when door opened, no hissing today! Allowed, slowly leaned into pets, purred.
Cage Condition:
No change
Reaction to assessor:
Sofrita remains neutral, resting on his cage bedding during the approach.
Reaction when softly spoken to:
Sofrita becomes alert with soft eyes.
Reaction to cage door opening:
Sofrita remains immobile in place, ears erect and forward.
Reaction to touch:
Sofrita hisses at first then slowly sniffs the assessor’s hand. She accepts the touch on the head then stands with tail up and body leans into the petting, appreciating the attention while she purrs.
Reaction to being picked up:
Briefly allows then jumps back into the cage.
ACTIVITY LEVEL:
Laid back
VOCAL:
Quiet
CHARACTER TYPE:
Calm

Sweet

Curious
BEHAVIOR DETERMINATION:
Average
Behavior Asilomar
H – Healthy
BEHAVIOR SUMMARY:
Sofrita interacts with the observer, appreciates attention, is easy to handle and tolerates all petting. This cat is showing behavior appropriate for new or experienced cat parents.
 

19-Feb-2018
Progress Exam
Vet Notes: 9:36 AM

S/O
-QAR/BAR, always hisses initially when approached but is very interactive and friendly afterwards; allows all handling
-mm pk/lgt pk, sl tacky
-no nasal discharge or sneezing
-no appetite, offered variety of diets including tuna
-eupnic
-soft abdomen
-underweight

A
1. Azotemia on intake, mild, suspect pre renal dehydration
2. Underweight-suspect underlying condition, r/o chronic GI vs other
3. Inappetance-r/o underlying nausea secondary to systemic dz vs chronic GI vs behavioral vs other

P
-gave 0.3 ml cerenia SQ
-mirtazapine 1/4 tab today
VET 991382

18-Feb-2018
Tech Exam
L V T Notes: 10:03 AM

weighed this AM- 5 pounds 1 oz
LVT-E 991215
18-Feb-2018
18-Feb-2018
Progress Exam
Vet Notes: 9:09 AM

Mild azotemia noted on intake, USG from 2/17 1.046 so suspect pre-renal; on SQF SID

S/O
-QAR/BAR, hisses initially when approached but is very friendly and interactive, allows all handling
-good appetite, volunteer noted that she loves dry food; large episode of tubular, partially digested vomiting in cage
-mm pk, sl tacky
-no nasal discharge or sneezing
-OU: open and clear
-eupnic
-abdomen slightly tense, no palpable abnormalities

A
1. Mild azotemia on intake, r/o dehydration vs other
2. Emaciated/underweight-suspect underlying condition with high consideration given to chronic GI disease
3. Vomiting-r/o eating too much/too fast vs diet change vs mild pancreatitis vs chronic GI (IBD vs lymphoma)

P
-azotemia on intake may indicate chronic dehydration instead of mild renal insufficiency; suspect there is an underlying condition causing mild dehydration and emaciated status, consideration given to chronic GI disease such as IBD or lymphoma
-consider full GI work up vs trial treatment of IBD after placement
-gave 0.3 ml cerenia SQ and 0.25 ml B12 SQ
VET 991382

17-Feb-2018
Progress Exam
Vet Notes: 4:18 PM

S: Eating and drinking. 3-4 % dehydrated based on skin tent. Very friendly on examination.

R = WNL
BCS = 3.7/9

Urinalysis results unremarkable – USG 1048 – Pre-renal azotemia

EENT: Eyes clear, ears clean, no nasal or ocular discharge noted
PLN: No enlargements noted
ABD: Non painful, no masses palpated
MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat
CNS: Mentation appropriate – no signs of neurologic abnormalities

Assessment: Pre-renal Azotemia as per USG results

Plan: Continue on current tx plan
VET 991493

17-Feb-2018

L V T Notes: 11:05 AM

Specific Gravity 1.046
BLD/HGB Neg
BIL Neg
UBG Normal
KET Neg
GLU 1+
PRO 1+
NIT —
LEU 2+
pH 7

17-Feb-2018
17-Feb-2018

L V T Notes: 10:36 AM

Given LRS 75ml SQ

17-Feb-2018
16-Feb-2018
Progress Exam
Vet Notes: 1:44 PM

Underweight, creat 2.1, BUN 63; started on SQF

S/O
-BAR, hisses initially when approached but allows handling and warms up quickly
-social eater! great appetite with warmed up friskies soft food mixed with fortiflora
-mm pk, sl tacky
-no nasal discharge or sneezing
-OU: open and clear
-eupneic, clear lung sounds, no murmurs or arrhythmias
-abdomen soft and doughy, no palpable abnormalitites
-BCS 3.5/9

A
1. Mild azotemia, r/o chronic renal disease exacerbated by dehydration vs dehydration vs other
2. Emaciated-suspect underlying condition such as IBD or hyperthyroidism — appetite good in medical

P
-continue SQF
-recommend rechecking renal values along with T4 in 7-10 days
-monitor appetite
-suspect underlying condition, although given the mild degree of azotemia, renal disease no suspected as the primary reason for emaciated status
VET-P 991445
16-Feb-2018
15-Feb-2018
Progress Exam
Vet Notes: 9:03 AM

Underweight, creat 2.1, BUN 63; started on SQF

S/O
-QAR, hisses initially when approached but allows handling and warms up quickly; starts head butting and making biscuits
-social eater! great appetite with warmed up friskies soft food mixed with fortiflora
-mm pk, sl tacky
-no nasal discharge or sneezing
-OU: open and clear
-eupnic, clear lung sounds, no murmurs or arrhythmias
-abdomen soft and doughy, no palpable abnormalitites
-BCS 3.5/9

A
1. Mild azotemia, r/o chronic renal disease exacerbated by dehydration vs dehydration vs other
2. Emaciated-suspect underlying condition such as IBD or hyperthyroidism

P
-continue SQF
-recommend rechecking renal values along with T4 in 7-10 days
-monitor appetite
-suspect underlying condition, although increased BUN may indicate renal disease, it may also be an indication of GI irritation; given the mild degree of azotemia, I do not suspect renal disease is the primary reason for emaciated status
VET 991382

13-Feb-2018
Blood Work Interpretation
Vet Notes: 5:35 PM

cbc/chem: bun 63, otherwise unremarkable
t4 wnl

pre-renal azotemia possible

gave 75 cc lrs
VET-P 991027

13-Feb-2018
Tech Exam
L V T Notes: 5:26 PM

75 ml of LRS given SQ as per Dr. 1027.
LVT-E 991154

13-Feb-2018
DVM Intake
Vet Notes: 5:13 PM

[DVM Intake]
DVM Intake Exam

Estimated age:7 years–seems younger but has “old” microchip
Microchip noted on Intake?y
Microchip Number (If Applicable):
0006d83851
History :abandoned in vacant apartment possibly for weeks

Subjective:

Observed Behavior -quiet, cries

Evidence of Cruelty seen -neglect

Evidence of Trauma seen -n

Objective

T =
P =200
R =wnl
BCS 1/9

EENT: Eyes : possible aging changes vs breed normal, ears clean, no nasal or ocular discharge noted
Oral Exam:milf tartar accum
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G: spay scar palpable
MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat
CNS: –possibly weak

Assessment: emaciated: undernourished vs secondary to illness

Prognosis:fair to guarded. If cat gains weight in care, prognosis is good

Plan:cbc/chem

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