MIKE -A0786734 -aka – A1037961
MIKE – A1037961
NEUTERED MALE, BLACK / WHITE, DOMESTIC SH,9 yrs
STRAY – STRAY WAIT, HOLD FOR ID Reason STRAY
Intake condition INJ SEVERE Intake Date 05/29/2015, From NY 11208, DueOut Date 06/02/2015,
Medical Behavior Evaluation GREEN
Medical Summary S/O: Patient presented as stray. Laying sternally on presentation. Very vocal but weak. Alert and responsive. Scan POSITIVE = 4A3E2B2243 mm = light pink, tacky hydration = 8-10% dehydrated (sunken eyes, prolonged skin tent) Integ = dull coat, dirty paws/nails EENT = OS: moderate to severe amount of mucopurulent ocular discharge oozing from the eye, covering the entire eye. When wiped away, a corneal ulcer was noted, approx 2 mm in diameter, in the central cornea. hyperemic conjunctiva. OD = clear; mild debris AU; nnd; absent tooth 204 – moderate periodontal disease H/L = nma, nsr; clear lung fields bilaterally Abdomen = snp, dehydrated peritoneal cavity (no fluid palpated) GU= neutered male LN = wnl CNS = dull but responsive MS = BCS: 2-3/9; muscle wasting over the hind legs, dorsum, ribs palpable. Patient is weak however will move voluntarily A: Severe deydration Corneal ulceration dental disease Px: Fair P: strongid – 0.58 mL given PO Activyl applied offered food – patient not interested Erythromycin, OS – continue BID x 10 days and recheck E-collar SQ fluids – 150 mL LRS BID x 3 days and recheck Recheck condition tomorrow – if no signs of improvement, recommend further diagnostics (combo test/blood work) vs. EHR.
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