CLINTA – A1033306
4-19-2015 Brooklyn
*** GONE 04/19/15 *** CALM CLINTA IS A LADY WHO NEEDS SOME TLC….Life has not been kind to CLINTA as you can see from her med profile. BUT YOU CAN ALSO SEE THAT CLINTA IS NOT GIVING UP!! She has had a consistently good appetite and her prognosis has been upped to FAIR…..PLEASE GIVE CLINTA A CHANCE TO REST AND HEAL….OFFER TO FOSTER AND THE RESCUE WILL HELP WITH THE VET BILLS WHILE YOU HELPING THIS AILING EBONY LADY…..FOSTER CLINTA AND HELP HER LIVE!!
Brooklyn Center
My name is CLINTA. My Animal ID # is A1033306. – P
I am a female black domestic sh. The shelter thinks I am about 10 YEARS old.
I came in the shelter as a STRAY on 04/15/2015 from NY 11238, owner surrender reason stated was STRAY.
MOST RECENT MEDICAL INFORMATION AND WEIGHT
04/18/2015 Exam Type OBSERVATION – Medical Rating is 4 NC – SEVERE CONDITIONS NOT CONTAGIOUS, Behavior Rating is NONE, Weight 4.3 LBS.
No urine in litter box but noticed urine on towel in cage.
04/15/2015 PET PROFILE MEMO
04/15/15 16:03pm very calm and easy to handle
WEB MEMO
No Web Memo
BEHAVIOR EVALUATION
No Behavior Summary
GROUP BEHAVIOR EVALUATION
No Group Behavior Summary
04/15/2015 INITIAL PHYSICAL EXAM
Medical rating was 4 NC – SEVERE CONDITIONS NOT CONTAGIOUS, behavior rating was NONE
scan negative female, ~10yrs old upon intake. lateral recumbent as per dr. memoli: HR: 270 TEMP: 98.2F no vaccines or flea prevention given blood drawn for combo test and CBC/CHEM PCV- 24%, JAUNDICE QAR NOSF
04/18/2015 RE-EXAM (LAST MAJOR EXAM)
Medical rating 4 NC – SEVERE CONDITIONS NOT CONTAGIOUS,
Vet check to recheck intention tremors, urine/stool production. Patient BAR on presentation this AM. Very good appetite – patient able to control tremors when eating No urine/stool production this morning Sl. prolonged skin tenting, sl. tacky mm – approx. 5% dehydrated small bladder palpated loops of intestines palpated – wnl H/L = wnl Patient able to stand on all 4 limbs and ambulate with slightly ataxic gait. A: Intention tremors – improving P: Continue current tx plan. ———————————————— VET CHECK – MONITOR CONDITION (NEUROLOGIC, DEHYDRATED, EMACIATED) BAR. MODERATELY DEHYDRATED. GREAT APPETITE. URINE ON BEDDING, NO STOOL NOTED ALLOWED ALL HANDLING PALE MM AMBULATORY, ATAXIC, INTENTION TREMORS NORMAL ABDOMINAL PALPATION – MODERATE SIZED, SOFT BLADDER; SOME STOOL IN COLON A: GERIATRIC, EMACIATED, DEHYDRATED, NEUROLOGIC, ANEMIC — APPEARS IMPROVED SINCE PRESENTATION P: CONTINUE WITH CURRENT TREATMENT AND MONITORING PLAN. RECOMMEND FULL GERIATRIC WORK UP WITH PLACEMENT. FAIR PROGNOSIS 4/16/15……….. Hx: Came in last night laterally recumbent, anemic. CBC/chem done but not yet interpreted. FeLV/FIV neg. S: Purrs when petted, social eater. Sternally recumbent. Intention tremor of head (gets worse when eating). O: QAR, 8% dehydrated (decreased skin turgor), BCS 2/9, MMs very pale pink EENT: No discharge OU, AU. Food crusted on nose and top of head. Clean teeth, but fractured L and R max canines. H/L: NSR, NMA. Eupnic. Quiet lung sounds. Purring intermittently. PLNS: Not enlarged. Abd: Soft, no pain on palpation, no masses palpated. Very tucked up. M/S/I: Sternally recumbent. No skin lesions noted. UG: Female. Neuro: Intention tremor noted while eating and soliciting petting. CBC: Hct 30% – nonregenerative anemia, very mild stress leukogram Chemistry: 2x elevated alk phos, 3x elevated ALT, slightly decreased creat (0.7) A: 1. Dehydrated, emaciated – R/O recent weakness and neurologic problems –> not eating or drinking 2. Anemic (nonregenerative) – R/O anemia of chronic disease, acute blood loss, decreased RBC production 3. Intention tremor – unknown cause, R/O head trauma, cerebellar hypoplasia, encephalitis, other 4. Weakness Short-term prognosis: Fair P: 1. Continue feeding and giving supportive care 2. LRS 100 ml SQ BID x5 days ***if not urinating well tonight/tomorrow, increase LRS!! 3. Recheck daily 1088
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