FLEX – A1035047

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Brooklyn Center

FLEX – A1035047

I am a neutered male, gray Domestic Shorthair mix.

The shelter staff think I am about 2 years old.

I weigh 6 pounds.

I was found in NY 11208.

I have been at the shelter since May 02, 2015.

Flex is an adult gray cat that was said to have been abandonded by his owner and surrendered as a stray by the finder. The counselor did not have any contact or handle Flex. Because Flex was lethargic he was rushed to medical.

MEDICAL:

5/2/15

Significant blood work abnormalities:

increased Alk phos: 254 U/L

increased ALT: 680 U/L

BUN: 39

Cholesterol: 243 mg/dL

increased TBili: 1.3 mg/dL

Na: 147 mmol/L

Cl: 108 mmol/L

Neutrophils normal but bands suspected

HCT: 53.3%

5/3/15

ANOREXIC, ATAXIC ALL 4 LIMBS, DEEP PAIN POSITIVIE, VENTRAL NECK FLEXION (K WNL), CAN AMBULATE SLOWLY THEN EVENTUALLY FALLS OVER, NO INTENTION TREMEORS, NO NYSTAGMUS OR HEAD TILT. AU WNL.

MM PINK AND TACKY, CRT < 2 S, ORAL WNL, PLN WNL, AUSC AND ABDOMINAL PALPATION WNL, OU WNL PLR +, MENACE +

NO VOMIT, YELLOW STAINED FLUID/MUCUS DIARRHEA

DDX: PRIMARY/SECONDARY HEPATIC DISEASE, ATAXIA STRONGLY SUGGESTIVE OF HEPATIC ENCEPHALOPATHY.

INFECTIOUS/INFLAMMATORY/SECONDARY INFILTRAITON (LIPIDOSIS)

P:

PARVO NEGATIVE

FELV/FIV NEGATIVE

ADVISED NH

IV CATHETER RIGHT CEPHALIC LRS 15 ML/HR (APPROX 2 XS MAINT)

LACTULOSE 1 CC PO BID X 5 DAYS

BAYTRIL 22.7MG/ML- 0.5 CC SQ SID X 10 DAYS

METRONIDAZOLE 0.7 CC PO BID X 10 DAYS

SYRINGE FED 40 CC KITTEN FOOD PO, TOOK WELL, CONTINUE 50 ML BID UNTIL EATING ON OWN

S/O: Patient presented in a plastic bin and described as lethargic and unable to walk.

mm = pink, sl. tacky, CRT<2sec.

hydration = prolonged skin tenting (approx. 7-8% dehydrated)

Integ= clean coat

EENT = clear OU, clean AU; nnd, clean teeth, mild gingivitis

H/L = nma, nsr; mildly harsh lung sounds bilaterally – eupneic, patient was also purring during auscultation

Abdomen = snp, small bladder

GU = MN

MS = BCS: 5/9; amb x 4

CNS = appropriate mentation, however very ataxic gait – difficulty coordinating. Propioception is weak – patient is able to place paws appropriately, but doesn’t reach or attempt to position himself when being placed on the ground. When sitting upright, patient places head low, ventrally. Tremors when placed on ground to walk. Seems stronger in front legs than hind.

LN = wnl

A:

Ataxia – r/o primary neurologic vs. orthopedic vs. metabolic (electrolyte derangement secondary to dehydration) vs. other

Dehydration – r/o pre-renal vs. renal vs. post-renal

Px: Fair until further information can be obtained

P:

Gave 100 mL SQ fluids (LRS) – patient seemed to be a bit more bright post-fluids

Offered food – patient took small bites

Recommend full blood work

Monitor for improvement daily, continue with SQ fluids daily

Significant blood work abnormalities:

increased Alk phos: 254 U/L

increased ALT: 680 U/L

BUN: 39

Cholesterol: 243 mg/dL

increased TBili: 1.3 mg/dL

Na: 147 mmol/L

Cl: 108 mmol/L

Neutrophils normal but bands suspected

HCT: 53.3%

New Hope left for the evening – will inform of case in the AM

N; 2 YO; 5.9 LB

Calm and relaxed, purring during exam

Ataxic

Dehydrated

Harsh brathing

BAR

Actyvil applied

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