DEAN – A1039775
*GONE* 06/13/15- Dean needs placement by 6 pm TONIGHT! He was picked up by an AC&C driver lying in front of a building. Our vet thinks Dean has liver disease, and will need to be transferred to a private veterinarian in order to receive further diagnostics and supportive care. Dean has been very cooperative during his exams, and has managed to charm our vet even in his condition! His appetite has improved slightly overnight, and he is less dehydrated, but he still needs vet care ASAP! Please help Dean get the help he needs, and pull him from BACC by 6 pm TONIGHT!
DEAN – A1039775
MALE, BLACK / WHITE, DOMESTIC SH,4 yrs
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition ILLNESS Intake Date 06/11/2015, From NY 11213, DueOut Date 06/14/2015,
Medical Initial: Green, Scan negative, Approx 4 years, QAR – presented as stray
Not interested in food
Drank some water in cage
mm = icteric, sl. tacky
hydration = sl. prolonged skin tenting (approx. 5-7% dehydrated)
EENT = clear OU, clean AU; nn; minimal amount of staining
H/L = poss. murmur ausculted; clear lung fields bilaterally
Abdomen = snp, poss. enlarged liver palpated; irregular left kidney palpated
GU = intact male
CNS = QAR, no obvious CNS deficits
MS = BCS: 4/9; weak but able to ambulate x 4.
LN = wnl
A: Icterus – r/o extra-hepatic vs. intrahepatic
poss heart murmur
poss. irregular kidney
P: Gave 150 mL LRS SQ – continue SID x 3 days
Gave 0.37 mL Cerenia SQ visceral pain + anti-emetic – continue daily x 4 more days
Recheck tomorrow – consider full blood work, combo test, inform New Hope – advise for abdominal ultrasound with full bloodwork.
If no improvement, recommend HER
S/O: Vet check for rechecking condition. Patient’s condition did not change overnight. No interest in food this AM. Patient did have interest in water and drank well. Urinated in cage overnight
improved hydration (sl. prolonged skin tent)
Organomegaly still palpable in cranial abdomen – non-painful
Ambulatory x 4, however patient remains weak.
A: icterus – r/o pre-hepatic (IMHA) vs. hepatic (hepatic lipidosis vs. cholangiohepatitis vs. neoplasia vs. infectious vs. other) vs. post-hepatic (cholestasis vs. biliary mucoceole)
organomegaly – likely liver
Px: Fair to guarded
P: Continue current treatment
Gave 3.75 mg Mirtazapine PO – next due 6/15/15
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