HOLLEY – A1035809

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Brooklyn Center

HOLLEY –  A1035809

 

Medical

 

Initial 05/09

Scan negative

M; 6 YO; 6.32 LB

Eyes swollen; large amount of discharge

Severe ear mites

Underweight

Matting on tail and back

QAR

Activyl applied

 

Re-exam 05/10

VC: PERIORBITAL SWELLING

 

S/O: BAR, EATING, FRIENDLY/ EASY TO HANDLE, NON AGRESSIVE

EENM: MM PINK AND MOIST, CRT 2 SEC, MODERATE GINGIVITIS, SEVERE PERIORBITAL SWELLING, CONJUNCTIVA EDEMATOUS AND ERYTHEMATOUS, YELLOW OCULAR D/C, SEVERE BILATERAL LOWER LID ENTROPION, CANNOT VISUALIZE GLOBE FULLY, POSSIBLE CORNEAL SCARRING

SEVERE AU MITE INFECTION, ACTIVELY BLEEDING SCRATCHES BEHIND PINNA

CV: NO MURMURS OR ARRHYTHMIAS

LUNGS: CLEAR

ABD: SOFT AND NONTENDER, NO MASSES

MS/INTEG: AMB X 4, BCS 3/9

MULTIPLE MATS ON DORSUM

NS: APPROPRIATE

PLN: NSF

GU: INTACT MALE

 

A:

SEVERE LOWER ENTROPION WITH SECONDARY CONJUNCTIVIS AND PERIORBITAL SWELLING, POSSIBLE CORNEAL ABRASIONS

AU MITE INFESTION

MATS ON DORSUM

P:

SEEK PLACEMENT WITH NH

SHAVED MATS ON DORSUM

CLEANED AU, APPLIED ANIMAX TO CANAL AND SCRATCHES ON CAUDAL PINNA

CLEANED OU, APPLIED ERYTHROMYCIN

LRS 100 CC SQ

BUPRENEX 0.18 CC SQ BID X 4 DAYS

ECOLLAR PLACED

PUT IN FOR TX FOR MITES AND RE TREAT IN 2 WEEKS

ERYTHROMYCIN OPTHALMIC OU BID X 10 DAYS

 

MONITOR AND RC

IF ENTROPION PERSIST ONCE PERIORBITAL SWELLING SUBSIDES WILL NEED SURGICAL REPAIR

GOOD PROGNOSIS

 

Re-exam 05/14

S/O:  Recheck for periorbital swelling. entropion.

 

Patient is QAR, cooperative for exam although shy.  Great appetite, urinating appropriately.  No stool, no c/s/v/d.

mm = pink, moist/CRT<2sec

H/L – nma, nsr, clear lung fields, bilaterally

Abdomen = snp

EENT = eyes – entropion bilaterally – patient is unwilling to open eyes for exam, but able to view globes from far away. OD appears better than OS – OS has possible corneal scarring, moderate blepharospasm OU.  periorbital swelling appears improved.

 

A:  Periorbital swelling- improved

Entropion

 

P:  Continue current treatment

Patient will likely need surgery for entropion repair.

Extend Buprenorphine

 

 

Behavior: Experience No Children

Notes: Please note that Holley is being treated at the time of the behavior assessment. This condition may affect some of the behaviors shown during evaluation. Holley was brought to the care center as a stray so we don’t have any behavioral history or tendencies previous to was seeing during the evaluation. At the time of the assessment he was displaying fearful behavior; does not seek attention from the assessor and becomes alert when the kennel was open. Retreats as I started to get closer. Holley does not allow much petting or handling. We recommend that this cat go to a home with experienced cat parents with no children.

 

Reaction to assessor:  attempts to hide upon my approach (3)

When spoken quietly:  continues to hide (3)

Reaction to door cage opening:  retreats (3)

Reaction to touch:  moves away from me, tries to flee cage (4)

Try picking cat up: not tolerant of this type of handling, very afraid, tries to flee.

 

Placement Determination: Experience no child

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