LADYBUG – A1039650

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Brooklyn Center

LADYBUG – A1039650
**Needs Veterinary Attention!**

FEMALE, GRAY TABBY, DOMESTIC SH,1 yr
STRAY – ONHOLDHERE, HOLD FOR ID Reason PET HEALTH
Intake condition EXAM REQ Intake Date 06/11/2015, From NY 11217, DueOut Date 06/14/2015,

MEDICAL
Initial: Green
S/O:  Patient presented as stray with trouble breathing.  Per good samaritan, patient has been in current condition for 2-3 days.  Not eating, no urine or stool produced.  On presentation, patient is QAR, able to hold head up, but does begin open mouth breathing when exerting energy.
Approx. 1 yr. old
Scan negative
mm = light pink, sl. tacky, CRT < 2 sec
hydration = prolonged skin tenting (approx. 5-7% dehydrated)
strength= fair
Integ = good hair coat
EENT = clear OU, clean AU, nnd; clean teeth, mild gingivitis
H/L = difficult to auscult heart, muffled sounds; lungs auscult moderately harsh.  Increased respiratory effort.  Dyspneic.
Abdomen = soft, patient exhibits some discomfort after prolonged palpation.  Seems more focused on breathing.  Soft mass palpated in the cranioventral abdomen.  Thin loops of intestines, small bladder otherwise.
GU = female, likely intact
CNS =  appropriate
MS = BCS: 3/9; Unable to assess gait, however patient is able to sit upright on the front limbs.
LN = wnl
A:  Dyspnea – r/o infectious (URI vs. pneumonia vs. FIP vs. other) vs. trauma (diaphragmatic hernia vs. pulmonary bullae/contusions vs. other)  vs. pleural effusion other
Px:  Guarded
P:  2 view abdominal radiographs performed – the right lung field appears to have a fluid opacity, diffusely, with only the caudal right lung lobe in view.  The left lung field appears to have a mild amount of fluid opacity.  There is a large amount of gas within what appears to be the stomach.
Gave 0.13 mL Buprenex
Gave approx 100 mL SQ LRS
Patient is on stray wait
patient cannot stay in shelter and needs further diagnostics.

Update:  Performed thoracocentesis and pulled approximately 80 mL of dark red/serosanguinous fluid from the right lung field.  Drew approximately 20-30 mL from the left lung field, tan – dark red colored serosanguinous fluid.
On retake radiographs, appeared to be minimal changes to the thoracic cavity.
Patient no longer is open mouth breathing and appears to slightly more comfortable, however tachypneic.

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