RED VELVET – A1057442

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Brooklyn Center

RED VELVET – A1057442

NEUTERED MALE, BRN TABBY / WHITE, DOMESTIC SH,5 yrs
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition UNSPECIFIE Intake Date 11/10/2015, From NY 11203, DueOut Date 11/13/2015,
Medical Behavior Evaluation GREEN
Medical Summary Scanned negative QARH – patient, allows all handling N~ 5 years Ears, eyes, nose, mouth clear – teth stained Overweight – does not like to walk. Some deterioration of muscles along the caudal spine. VC requested. Urine scald along abdomen and hind legs. Coat – fouled with feces and urine. Flea dirt noted; no live parasites found. NOSF
Weight 14.0

S: ate a small amount of dry food, very large amount of urine in the cage

O:

Appearance: dull to QAR, ~10-12% dehydrated

Integument: unkempt haircoat, polonged skin turgor

EENT: OU iris atrophy but otherwise clear, No nasal d/c

Oral cavity: MM pale pink, CRT <2sec, healthy dentition with mild staining on canines

PLN: WNL

H/L: No murmur or arrhythmias, Lungs clear, slightly tachypnic

ABD: Soft non painful, no palpable masses or organomegaly, large palpalbe bladder

U/G: normal external genitalia

M/S: Amb x 4, no appreciable lameness

Neuro: NSF

Urine dip- Glucosuria, ketone negative

A: Glucosuria- r/o DM vs. less likely other

dehydrated- r/o secondary to unregulated DM

tachypnic-r/o secondary to metabolic acidosis secondary to unregulated DM vs. less likely primary pulmonary vs. pleural effusion

P: Recommend immediate NH placement and transfer to a primary care facility to start on insulin for long term care. Will start SQ fluids while in hospital. Will move to medical to obervation and alert NH

Prognosis: Good with appropriate treatement

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