MARK – A1038506
6-6-2015 Brooklyn
*GONE* 06/06/15- Mark was picked up as a stray and brought into BACC. Mark is dehydrated and has some pretty bad ulcers in his mouth, which will require some follow up care. He has not eaten much since being brought into the shelter and can usually be found curled up on his blanket, but he does perk up a bit when you interact with him. He gently closes his eyes and leans in while you scratch under his chin! Please help this sweet guy get the TLC he needs, and pull Mark from BACC today!
Brooklyn Center
MARK – A1038506
MALE, WHITE / BLACK, DOMESTIC SH,8 yrs
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition ILLNESS Intake Date 06/02/2015, From NY 11220, DueOut Date 06/05/2015,
Medical Behavior Evaluation GREEN
Medical Summary Scan negative Sociable, tolerate handling Intact male, approximately 8 yrs old Severe fleas infestation Severe dehydration Dwowling Moderate tartar and gingivitis Temp-98.5 F Very poor appetite Mpnd Applied activyle Bar
Weight 7.2
Medical
Initial: Green
Scan negative
Sociable, tolerate handling
Intact male, approximately 8 yrs old
Severe fleas infestation
Severe dehydration
Drooling
Moderate tartar and gingivitis
Temp-98.5 F
Very poor appetite
Mpnd
Applied activyl
Bar
Re-exam: 6/02
S/O: Q-BAR, ALLOWED HANDLING WITHOUT AGGRESSION, MODERATELY 8% DEHYDRATED
EENM: MM PINK AND TACKY, CRT APPROX 2 SEC, HYPERSALIVATING/FROTHY, MODERATE GINGIVITIS AND CALCULI, MULTIPLE EAR LACERATIONS RIGHT PINNA
MULTIPLE ORAL ULCERATIONS: RIGHT TONGUE APPROX 4MM, LARGE VENTRAL LINGUAL SLOUGHING ULCER, SEVERE HALITOSIS
CV: NO MURMURS OR ARRHYTHMIAS
LUNGS: CLEAR
ABD: SOFT AND NONTENDER, SUCKED UP, NO MASSES
MS/INTEG: AMB X 4, BCS 3/9
NS: APPROPRIATE
PLN: NSF
GU: IN TACT MALE
FELV/FIV NEGATIVE
A:
MULTIPLE ORAL ULCERATIONS
UNDERWEIGHT
DEHYDRATED
P:
BUPRENEX 0.2 CC SQ BID X 4 DAYS
LRS 100 CC SID X 4 DAYS
PEN G 0.5 CC SQ
BAYTRIL 0.5 CC SQ SID X 7 DAYS
CONTINUE TO MONITOR AND RECHECK
FAIR PROGNOSIS
Re-exam: 6/04
S/O: Vet check for monitoring hydration and appetite. Patient presented yesterday with severe oral ulcerations.
On presentation, patient was QAR, tolerable of handling. Did not appear to have eaten food overnight.
mm = light pink, CRT< 2s, moist
hydration = moist mm, sl. prolonged skin tenting
Expressed interest in food by licking a small amount off finger.
H/L = nma, clear lung fields bilaterally
EENT = no ocular discharge, dried nasal discharge covering nostrils, bilaterally. Oral ulcerations on upper lip mucosa bilaterally. Unable to view sublingual ulcer.
A: Oral ulcerations
Dehydration
underweight
Px: Fair
P: Continue current treatment plan
Increase LRS to BID
Add Mirtazapine once (not due again until 6/7)
Consider adding Doxycycline if no improvement
Cleaned nose/face.
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