TEX aka TESSY – 23149

Medical:

22-Mar-2018
Progress Exam
Vet Notes: 2:03 PM

SO
reported to have been sneezing for 2 days.

-no nasal discharge, sneezing or coughing on observation
-eupnic
-eyes clear; no discharge or blepharospasm.

A
sneezing?

P
recheck in 2 days.
20-Mar-2018

Medical Assistant: 9:09 PM

please run UA if sample available–no urine available. Will check through out the night and move to LVT. However, it appears the analysis was completed on 3/18
19-Mar-2018
Tech Exam
L V T Notes: 9:08 PM

no urine available in nosorb box. will monitor and if available will perform UA
19-Mar-2018
Progress Exam
Vet Notes: 5:06 PM

2 view full body radiographs: abdomen: mildly decreased serosal detail, subjectively enlarged liver with slightly rounded margis; small intestinal tract appears empty but intestinal walls appear subjectively thickened; normal fecal material in descending colon with with softer fecal material more proximally; thorax: possible mild hyperinflation, otherwise unremarkable; orthopedic and spinal structures unremarkable

A
1. Hepatomegaly, mild
2. Decreased serosal detail-r/o secondary to decreased BCS vs ascites
3. Intestinal thickening-r/o parasites vs FIP vs other

Vet Notes: 4:58 PM

Part of a community of cats, finder reported inappetance and crouched gait for about 1 week; blood work was overall unremarkable aside from mild hyperglycemia (243) and mild anemia

S/O
-QAR, unsocialized, will flee!
-mild appetite
-mm pk, sl tacky; CRT <2 sec; adult dentitia with no significant tartar/staining; no obvious oral wounds
-no nasal discharge or sneezing
-OU: open and clear
-eupnic, clear lung sounds, no murmurs/arrhythmias
-soft abdomen, intestines palpate slightly thickened/ropey
-placed on harness, has crouched posture but suspect it is behavioral; no obvious lameness or orthopedic injury

A
1. h/o crouched posture-r/o behavioral vs other
2. Inappetance
3. Intestinal thickening

P
-sedated with 0.2 ml torb/0.2 ml dexdomitor/0.2 ml IM for radiographs
-gave 0.4 ml praziquantel SQ
-cerenia 0.4 ml SQ
-0.25 B12 SQ
-prognosis: open, signs may be related to treatable illness such as parasites but if weight loss, inappetance continues, then FIP may be considered
19-Mar-2018
Tech Exam
L V T Notes: 3:58 PM

Sedated at 3:30 pm with dexdomitor 0.2ml and Butorphanol 0.2ml (bottle #4). Also gave ketamine (bottle #19) at 3:40 pm for further sedation. Radiographs taken of the pelvis, abdomen, and chest. 100 ml SQF LRS administered, as well as 0.3ml cerenia and 0.25ml b-12 (SQ).
Reversed dexdom with Antiseden 0.2ml IM.
19-Mar-2018
Tech Exam
L V T Notes: 10:42 AM

No urine available in nosorb box at this time. Appropriate sign posted on kennel and repeat check for overnight placed in the event that a urine sample does not become available today.
18-Mar-2018
DVM Intake
Blood Work Interpretation
Vet Notes: 12:51 PM

CBC:
Hct 32.9% which is low but WNL
WBC 7.51 k/ul
Plt 319 k/ul

Chemistry:
Glu high (243 mg/dl) – R/O stress hyperglycemia vs. diabetes
Creat low (0.6 mg/dl) – R/O weight loss
Phos high (8.4 mg/dl) – R/O normal for kittens

ASSESSMENT: Recent hx anorexia and walking in a crouched stance – R/O neurological vs. hyperthyroid vs. diabetic

PLAN:
1. Litter pan in kennel with No Sorb for urine collection –> urinalysis
2. Run T4
3. Monitor gait
4. Consider rads

Vet Notes: 10:38 AM

DVM Intake Exam

Estimated age: Reported approx 8 months – this is reasonable given dentition and secondary sex characteristics
Microchip noted on Intake? Scanned negative – MC placed

History : Part of a colony. Caretaker says that for the past week, this pt has not been eating, and has been walking with a crouched stance and not acting normally.

Subjective: Alert, FLEES immediately and climbs up the counter, runs under the chairs, runs all over and hides behind anything he can get behind.

Observed Behavior – Once restrained in a towel, pt meows and is tense, but allows handling without any growling, hissing or other signs of aggression

Evidence of Cruelty seen – None

Evidence of Trauma seen – None

Objective
BAR-H, MMs pale pink and moist, BCS 3.5/9
EENT: Eyes clear, ears clean, no nasal or ocular discharge noted
Oral Exam: Clean adult teeth
PLN: No enlargements noted
H/L: NSR, NMA, HR 200. Lungs clear, eupnic
ABD: Soft, non painful, no masses palpated, not distended
U/G: Male intact, testicles S/S
MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat.
CNS: Mentation appropriate – no signs of neurologic abnormalities. Good muscle tone and good patellar reflexes.
Rectal: Normal externally

Assessment: 1-wk hx of anorexia and gait abnormality. On exam, weight loss is the only finding. R/O metabolic disease (hyperthyroid, diabetes, other) vs. neurological abnormality (HBC/spinal injury) vs. other

Prognosis: Fair

Plan: CBC/chemistry

SURGERY:
Okay for surgery
Behavior:

KNOWN HISTORY:
Tessy was brought in as a stray, so we don’t have any behavioral history or tendencies in a home environment.
MEDICAL BEHAVIOR:
3/18/18
Observed Behavior – Once restrained in a towel, pt meows and is tense, but allows handling
ENRICHMENT NOTES:
3/19/18
Reported not eating, trouble walking. Hunched at back under kuranda bed, eyes dilated, tense. Stayed crouched in place when door opened, eyes focused on my hand. Tolerated pets, but remained stiff, eyes darting, no other response.

3/20/18
Crouched behind den, tense, alert, eyes dilated. Stayed hunched in place when door opened. Tolerated pets, but put ears sideways, eyes focused on me. No other response, unwilling to come forward.

3/21/18
Curled up next to den, tense, head down, eyes dilated. Lifted head and became alert when spoken to, then fled into den when door opened. Hissed quietly, leaned away to avoid touch.
Cage Condition:
No change
Reaction to assessor:
Tessy remains tense, crouched position turned sideways at the back during the approach.
Reaction when softly spoken to:
Tessy becomes alert with eyes wide open, pupils dilated.
Reaction to cage door opening:
Tessy remains tightly curled up in place with ears erect and forward.
Reaction to touch:
Tessy accepts a brief touch on the head, but increases distance and avoids contact.
ACTIVITY LEVEL:
Laid back
VOCAL:
Quiet
CHARACTER TYPE:
Skittish

Independent
BEHAVIOR DETERMINATION:
Experienced, adult only
Behavior Asilomar
TM – Treatable-Manageable
BEHAVIOR SUMMARY:
Tessy may be a little more independent, and may need time to warm up to his new home. Due to the behaviors seen in the care center, we feel that this cat will do best in an experienced, adult only home who understands this cat may need time to warm up to his new home and family at his own pace.