SOPHIE – 8806
Safe - 10-24-2017 Brooklyn
***SAFE 10/24/17**** SWEET SOPHIE RECOVERING FROM PYOMETRA SURGERY NEEDS YOU! The Shelter staff says: ” Sophie had an open pyometra when she came into the Care center on Wednesday- Our awesome medical staff was able to perform a spay and get her on medication for the infection. Sophie is getting better but needs some more TLC to make a full recovery! Please consider taking her today.” Well the shelter does not want to wait any longer for this pretty panther girl to recuperate. They want her out tonight! Sophie allows gentle petting but needs a place to recover fully so her true purrsonality will shine. PLEASE HELP SOPHIE TONIGHT BY RESERVING HER BEFORE NOON!!
Brooklyn Center
Hello, my name is Sophie. My animal id is #8806. I am a desexed female black cat at the Brooklyn Animal Care Center. The shelter thinks i am about 2 years old. – P
I came into the shelter as a stray on 04-Oct-2017.
Let’s get to know each other a bit more…
Sophie is at-risk with an adult only determination. Her finder kept her for a little while and reports she is very fearful and stayed hidden, but she will approach after a few days and allow people to handle her. She currently displays fearful behavior and does not appear to be thriving in the stressful shelter environment. She focuses on the person and attempts to shift away. She will allow gentle petting after a few attempts, but looks very uncomfortable and remains tense.
My medical notes are…
Weight: 12.6 lbs
Vet Notes
Post Surgery Note
L V T Notes
[DVM Intake] Estimated age: 2 yo intact F Microchip noted on Intake? neg History : Stray. Finder found cat in hall 3 weeks ago – suspects left by neighbor – cat appeared injured. Finder kept for 3 weeks. Subjective: QAR- H. Hair loss around lips and on abd. Distended abd. Vulvar d/c. Observed Behavior – BARH Evidence of Cruelty seen -n Evidence of Trauma seen -n Objective T =102.1 P = 200 R = eup BCS= 5/9 EENT: Eyes clear, ears clean, no nasal discharge noted. Oral Exam: cln PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated but distended abd. U/G: Female – intact – no spay scar seen. MP vulvar d/c. Nipples small. MSI: Ambulatory x 4 – no signs of injury, skin free of parasites, no masses noted. Alopecia rostral max and mandibular muzzle and on ventral abdomen up to chest, otherwise healthy hair coat. No crusts or erythema. Wood’s lamp – negative. CNS: mentation appropriate – no signs of neurologic abnormalities Rectal: not done Assessment: 1) 2 yo intact F DSH. 2) Vulvar d/c and distended abd – r/o open pyometra. 3) Alopecia on muzzle and ventral chest/ abd – r/o allergies vs stress grooming vs infxn. Prognosis: Fair to good. Plan: Wood’s lamp – neg. Abd x-rays lat and v/d – bilateral prominent distension of uterine horns, otherwise NSF. Pen G 0.7cc sq. SQF 150 cc. Set up for sx tomorrow. Clavamox 1.3 cc po bid – start tonight. SURGERY: Okay for surgery
Re-exam History : Stray intake 10/4-had an open pyometra. Surgery 10/5 revealed very large distended pyometra with adhesion to the omentum and torsion. Was given pen G, SQ LRS, and started on clavamox, injectable baytril, and simbadol. IVC removed 10/5. Alopecia noted on chest-Wood’s Lamp negative. Subjective: BARH. No c/s/v/d. Decreased appetite. Seems comfortable on abdominal palpation. Objective P = wnl R = wnl BCS= 5/9 EENT: Eyes clear, ears clean, no nasal discharge noted. Oral Exam: Pink and moist mm, mild dental disease PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic ABD: Tense but non painful, no masses palpated U/G: FS, incision and tattoo cdi, no MGTs, no vulvar dc MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat. N CNS: mentation appropriate – no signs of neurologic abnormalities Assessment: Pyometra surgery 10/5 Alopecia on muzzle and ventral chest/ abd – r/o allergies vs stress grooming vs infxn Decreased appetite Plan: Continue clavamox 13.75mg/kg PO BID Continue simbadol 0.24mg/kg SQ SID Continue injectable baytril 5mg/kg SID Give LRS SQ 100ml once Give cerenia 1mg/kg SQ once Give mirtazapine 3.75mg PO once Recheck daily Good prognosis
Re-exam History : Stray intake 10/4-had an open pyometra. Surgery 10/5 revealed very large distended pyometra with adhesion to the omentum and torsion. Was given pen G, SQ LRS, and started on clavamox, injectable baytril, and simbadol. IVC removed 10/5. Alopecia noted on chest-Wood’s Lamp negative. Subjective: BARH. Eating a/d. Tense and distended abdomen. No c/s/v/d. Objective P = wnl R = wnl BCS= 5/9 EENT: Eyes clear, ears clean, no nasal discharge noted. PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic ABD: Tense, painful, and distended, no masses palpated U/G: FS, incision and tattoo cdi, no MGTs, no vulvar dc MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat. CNS: mentation appropriate – no signs of neurologic abnormalities Assessment: Pyometra surgery 10/5 Tense, distended abdomen Alopecia on muzzle and ventral chest/ abd – r/o allergies vs stress grooming vs infxn Decreased appetite Severe leukocytosis Plan: Continue clavamox 13.75mg/kg PO BID until 10/13 Continue simbadol 0.24mg/kg SQ SID-extend x3d Continue injectable baytril 5mg/kg SID until 10/10 Offer a/d 2 view AXR-nsf, no free fluid Telazol 0.15ml IM for AXR Recheck daily CBC-severe leukocytosis 62.05 (2.87-17.02) with lymphocytosis 8.88 (0.92-6.88) monocytosis 0.76 (0.05-0.67), and neutrophilia 52.05 (1.48-10.29) with bands, anemia 26.7% (30.3-52.3) Chem-low ALP 12 (14-111), low BUN 15 (16-36) Rec hospitalization for IV fluids and abx. Good prognosis
Re-exam History : Stray intake 10/4-had an open pyometra. Surgery 10/5 revealed very large distended pyometra with adhesion to the omentum and torsion. Was given pen G, SQ LRS, and started on clavamox, injectable baytril, and simbadol. IVC removed 10/5. Alopecia noted on chest-Wood’s Lamp negative. 10/7: CBC-severe leukocytosis 62.05 (2.87-17.02) with lymphocytosis 8.88 (0.92-6.88) monocytosis 0.76 (0.05-0.67), and neutrophilia 52.05 (1.48-10.29) with bands, anemia 26.7% (30.3-52.3) Chem-low ALP 12 (14-111), low BUN 15 (16-36) 2 view AXR-nsf, no free fluid Subjective: BARH. Eating well. Tense and distended abdomen. No c/s/v/d. Seems less nervous today. Objective P = wnl R = wnl BCS= 5/9 EENT: Eyes clear, ears clean, no nasal discharge noted. PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic ABD: Tense and distended, no masses palpated U/G: FS, incision and tattoo cdi, no MGTs, no vulvar dc MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat. CNS: mentation appropriate – no signs of neurologic abnormalities Assessment: Pyometra surgery 10/5 Tense, distended abdomen Alopecia on muzzle and ventral chest/ abd – r/o allergies vs stress grooming vs infxn Decreased appetite-resolved Severe leukocytosis Plan: Continue clavamox 13.75mg/kg PO BID until 10/13-may need extension Continue simbadol 0.24mg/kg SQ SID until 10/11 Continue injectable baytril 5mg/kg SID until 10/10-may need extension Offer a/d Recheck daily Rec hospitalization for IV fluids and abx. Good prognosis
Re-exam History : Stray intake 10/4-had an open pyometra. Surgery 10/5 revealed very large distended pyometra with adhesion to the omentum and torsion. Was given pen G, SQ LRS, and started on clavamox, injectable baytril, and simbadol. IVC removed 10/5. Alopecia noted on chest-Wood’s Lamp negative. 10/7: CBC-severe leukocytosis 62.05 (2.87-17.02) with lymphocytosis 8.88 (0.92-6.88) monocytosis 0.76 (0.05-0.67), and neutrophilia 52.05 (1.48-10.29) with bands, anemia 26.7% (30.3-52.3) Chem-low ALP 12 (14-111), low BUN 15 (16-36) 2 view AXR-nsf, no free fluid Subjective: BAR, ~5% dehydrated. Eating well but only likes a/d. Abdomen seems more comfortable today but a new heart murmur was noted on exam. Pink mm. No c/s/v/d. Seems less nervous today. Objective P = wnl R = wnl BCS= 5/9 EENT: Eyes clear, ears clean, no nasal discharge noted. PLN: No enlargements noted H/L: Grade 3/6 HM, NSR, CRT < 2 and pink, Lungs clear, eupneic ABD: snp, distended, no masses palpated U/G: FS, incision and tattoo cdi, no MGTs, no vulvar dc MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat. CNS: mentation appropriate – no signs of neurologic abnormalities Assessment: Pyometra surgery 10/5 Grade 3/6 HM r/o anemia vs heart disease vs other Dehydrated Tense, distended abdomen-improving Alopecia on muzzle and ventral chest/ abd – r/o allergies vs stress grooming vs infxn Decreased appetite-resolved Severe leukocytosis Plan: Start SQ LRS 20ml/kg SID x3d Continue clavamox 13.75mg/kg PO BID until 10/13-may need extension Continue simbadol 0.24mg/kg SQ SID until 10/11 Continue injectable baytril 5mg/kg SID until 10/10-may need extension Offer a/d Recheck daily/monitor heart murmur Recheck daily PCV/TS PCV/TS: 25%/7.2 Rec hospitalization for IV fluids and abx. Good prognosis
Vet Notes Re-exam History : Stray intake 10/4-had an open pyometra. Surgery 10/5 revealed very large distended pyometra with adhesion to the omentum and torsion. Was given pen G, SQ LRS, and started on clavamox, injectable baytril, and simbadol. IVC removed 10/5. Alopecia noted on chest-Wood’s Lamp negative. 10/7: CBC-severe leukocytosis 62.05 (2.87-17.02) with lymphocytosis 8.88 (0.92-6.88) monocytosis 0.76 (0.05-0.67), and neutrophilia 52.05 (1.48-10.29) with bands, anemia 26.7% (30.3-52.3) Chem-low ALP 12 (14-111), low BUN 15 (16-36) 2 view AXR-nsf, no free fluid Subjective: BAR, hydration good today. Eating well today. Abdomen seems more comfortable today but a new heart murmur was noted on exam 2 days ago. Pink mm. No c/s/v/d. Seems less nervous today. Objective P = wnl R = wnl BCS= 5/9 EENT: Eyes clear, ears clean, no nasal discharge noted. PLN: No enlargements noted H/L: Grade 3/6 HM, NSR, CRT < 2 and pink, Lungs clear, eupneic ABD: snp, distended, no masses palpated U/G: FS, incision and tattoo cdi, no MGTs, no vulvar dc MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat. CNS: mentation appropriate – no signs of neurologic abnormalities Assessment: Pyometra surgery 10/5 Grade 3/6 HM r/o anemia vs heart disease vs other Alopecia on muzzle and ventral chest/ abd – r/o allergies vs stress grooming vs infxn Decreased appetite-resolved Severe leukocytosis Plan: Continue SQ LRS 20ml/kg SID x3d Continue clavamox 13.75mg/kg PO BID until 10/13-may need extension Continue simbadol 0.24mg/kg SQ SID until 10/11 Continue injectable baytril 5mg/kg SID through 10/10 Offer any food Recheck daily/monitor heart murmur Recheck daily PCV/TS PCV/TS: 25%/7.2 Rec hospitalization for IV fluids and abx. Good prognosis
Vet Notes Re-exam
History : Stray intake 10/4-had an open pyometra. Surgery 10/5 revealed very large distended pyometra with adhesion to the omentum and torsion. Was given pen G, SQ LRS, and started on clavamox, injectable baytril, and simbadol. IVC removed 10/5. Alopecia noted on chest-Wood’s Lamp negative. 10/7: CBC-severe leukocytosis 62.05 (2.87-17.02) with lymphocytosis 8.88 (0.92-6.88) monocytosis 0.76 (0.05-0.67), and neutrophilia 52.05 (1.48-10.29) with bands, anemia 26.7% (30.3-52.3) Chem-low ALP 12 (14-111), low BUN 15 (16-36) 2 view AXR-nsf, no free fluid Subjective: BAR, hydration improved. Eating well today. Abdomen seems more comfortable today but a new heart murmur was noted on exam. Pink mm. No c/s/v/d. Seems less nervous today. Objective P = wnl R = wnl BCS= 5/9 EENT: Eyes clear, ears clean, no nasal discharge noted. PLN: No enlargements noted H/L: Grade 3/6 HM, NSR, CRT < 2 and pink, Lungs clear, eupneic ABD: snp, no distension/tense today, no masses palpated U/G: FS, incision and tattoo cdi, no MGTs, no vulvar dc MSI: Ambulatory x 4, skin free of parasites, no masses noted, alopecia around mouth. CNS: mentation appropriate – no signs of neurologic abnormalities Assessment: Pyometra surgery 10/5 Grade 3/6 HM r/o anemia vs heart disease vs other Dehydrated Tense, distended abdomen-resolved Alopecia on muzzle and ventral chest/ abd – r/o allergies vs stress grooming vs infxn Decreased appetite-resolved Severe leukocytosis Plan: continue SQ LRS 20ml/kg SID x3d Continue clavamox 13.75mg/kg PO BID until 10/13-may need extension Continue simbadol 0.24mg/kg SQ SID until 10/11 Continue injectable baytril 5mg/kg SID until 10/10-may need extension Offer any food Recheck daily/monitor heart murmur Recheck daily PCV/TS PCV/TS: 25%/7.2 prior Rec hospitalization for IV fluids and abx ini. Good prognosis
Details on my behavior are…
Behavior Assessment Date: 10/9/2017 KNOWN HISTORY: Sophie was brought in as a stray, so there is no information on her behavior history or tendencies in a home environment. Her finder kept her in their home for a short while and reports she Sophie is very fearful around the people approach. She hides under the bed. After a few days she will approach and allow to be picked up. MEDICAL BEHAVIOR: Bright, alert, responsive. ENRICHMENT NOTES: 10/09/17 Lying in back of kennel, body tense and eyes wide. She leans her head away from me as I reach forward and tolerates petting while looking around the room – moving as if looking for an escape. Sniffs treats offered but does not eat them during our interaction. Needs more time to adjust. Cage Condition: Cage is slightly re-arranged Reaction to assessor: Sophie is sitting upright by the back, looking with dilated eyes. Reaction when softly spoken to: Sophie focuses on the assessor, but her eyes begin to soften up after a while. Reaction to cage door opening: Sophie becomes alert and lowers her body. Reaction to touch: Sophie focuses on the assessor’s hand and attempts to shift away. She allows gentle strokes, but continues to shift away. After a few tries, she remains in place and closes her eyes, allowing the assessor to stroke her gently on her head. Her ears tilt sideways and she remains tense, but she tolerates all petting. ACTIVITY LEVEL: Moderate VOCAL: Quiet CHARACTER TYPE: Shy Easy going Timid POTENTIAL CHALLENGES: Fearful Potential challenges comments: Sophie has displayed fearful behavior during their stay in the care center and may be uncomfortable with extended handling. A fearful cat will feel more relaxed when given options, so provide her with the chance to move closer, investigate, or interact with you. Be sure to offer incentive such as treats or play time whenever the cat makes a small positive step. Please speak to an adoption counselor for additional information on methods to desensitize your cat to their fear stimulus. BEHAVIOR DETERMINATION: Experienced, adult only Behavior Asilomar TM – Treatable-Manageable BEHAVIOR SUMMARY: Sophie tolerates attention and petting but may be fearful or stressed in the shelter, and may be intimidated by small children. She may need time to warm up to her new home and family. Due to the behaviors seen in the care center, we feel that this cat will do best in an experienced, adult only home.
10/09/17 Behavior: Adult Only
details for pyometra spay: engorged horns, serosal detail hyperemic, injected vessels. right distal uterine horn close to ovary had adhesion with omentum. Left horns was tortuous and twisted onto itself. the uterus was removed routinely, the abdomen flushed with warmed saline. Added IV baytril ( 22.7mg ) intraoperatively. Continue with SC baytril 22.7mg SID x 5 days
[Anesthesia Template] Pre Medication (recorded in Mls) Dexdomitor: Acepromazine: Ketamine: Midazolam: Diazepam: Hydromorphone: Morphine: Buprenorphine: 0.79cc Simbadol Butorphanol: Nalbuphine: Local Anesthetic Blocks: Lidocaine: (For intubation) Bupivicane: Anesthetic Induction Propofol: Ketamine: Midazolam: Diazepam: Telazol:0.15cc Gas Maintenance: Isoflorane % : 2 [Surgery Template – Cat Spay] Was this cat in heat, pregnant or have a pyometra? Pyometra – see vet note. Ventral Midline Incision Ovaries Ligated with: Uterine Body Ligated with: Abdominal Closure: Green Linear Tattoo Placed on Midline Surgeon:1204 Additional Comments:IV Catheter placed by 1059 and LRS given 60ml/hr during procedure; reduced to 30ml/hr post surgery and removed by 8:00pm.
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