JIMMY – A1099332
Gone - 12-14-2016 Manhattan
JIMMY – A1099332
***NEEDS TO GO TO A VET BY 7PM Today, 12/13/16***
MALE, TAN / WHITE, AM PIT BULL TER MIX, 5 yrs
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition UNSPECIFIE Intake Date 12/10/2016, From NY 10471, DueOut Date 12/13/2016,
Medical Behavior Evaluation BLUE
Medical Summary Microchip: negative Sex: intact male Age: appx 5y Mentation: QARH Eyes: clear, OS polychromatic blue and brown and OD brown Ears: clean Nose: no d/c Teeth: some abraded areas on lips, mild to moderate staining If abnormal BCS: underweight, obvious hip points and ribs Skin: target lesions udner some bites Hair Coat: some spots of alopecia from scratching around ticks, otherwise WNL Declawed: N/A Any injuries: tick infestation, no except self trauma from pruritis Behavior: at first tense but allowed handling and stood well for removing ticks, would wag when spoken to Medication: N/A, preventatives given (tick plus activyl) TID sign placed
RE EXAM: 12/12
S: stray admitted overnight on 12/10-11, tick infestation and emaciation noted, was QAR/sleeping in kennel on rounds yesterday, vomiting seen overnight, icteric this morning; O:QAR; dehydrated; AU: icteric pinnae; OU: icteric sclera; Oral: moderate dental tarta; Int: tick found on dorsal neck; Lnn: no lymphadenopathy; CV: NMA, s&s pulses, icteric tacky mm; Resp: lungs clear x4, eupnic; Abd: SNP; Repro: intact male; MS: 4x ambulatory ROM WNL x4, no joint effusion or pain on palpation, emaciated BCS 2/9; Neuro: PLRs, menace & mentation WNL, CPs WNL, no ataxia; A:; hemolysis (tick borne inx vs babesia vs IMHA vs other inx) vs primary liver disease (hepatitis vs hepatopathy) vs cholestasis; emaciated; P:4Dx negative; CBC mild anemia in face of dehydration, neutrophilia with band neutrophils suspected, severe monocytosis; Chem severe BUN Creat & Phos elevation, mild hyperGLob, elevated ALP/ALT/GGT & T bili elevation, hypo Na and hypo Cl; r/o hi suspicion for leptospirosis infection; px: poor to grave
12/13/16 12:14 s/o: still icteric; QAR; growled softly when tried to pill/check gums but behaved pretty well
stool light colored (acholic?); on very low fluid rate; abdomen wnl a:liver disease vs tick born disease vs leptospirosis vs babesia p: increase fluid rate to 100ml/hour; gave baytril 200mg sid x 10d (gave first dose), repeat tonight; note: do would not eat doxy pills; repeat blood in two hours , lepto titer; guarded prognosis; update: cbc/chem essentially unchanged
A staff member writes: Handsome and sweet boy Jimmy with his gorgeous heterochromia eyes was found in a park and was brought in by a park Ranger. He was covered in ticks and emaciated. This sweet boy is jaundice and may possibly have leptospirosis. Will you be the help he needs?
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