KAI – 10087
Safe - 11-2-2017 Manhattan
KAI – 10087
**PNEUMONIA, NEEDS VET CARE ASAP**
5y Black Spayed Female 14lbs. Intake: 11/2/17
Medical: 11/2; Pt has been coughing, hacking, sneezing. She occasionally has a small amount of blood on her nose after sneezing. She has a poor appetite but is drinking water.; SUBJECTIVE EVALUATION: Alert, slightly tense, allows all handling; OBJECTIVE EXAM: QAR, estimated 5-8% dehydrated based on decreased skin turgor, BCS 5/9, MMs pink. Temp 103.1.; EENT: Mild serous nasal discharge. No discharge OU, AU. Moderate tartar and gingivitis.; PLNs: Not enlarged.; H/L: NSR, NMA. Tachypneic – RR 48, slightly increased work of breathing. Hacking cough. Quiet lung sounds.; Abd: Soft, no pain on palpation, no masses palpated; M/S/I: Amb x4. No skin lesions noted.; UG: Female; Neuro: Alert and appropriate; Right lateral and DV chest rads – heavy alveolar pattern in the right and left middle lung fields with air bronchograms.; ASSESSMENT:1. Pneumonia, 2. Dental disease; PLAN: 1. Start IV LRS at 50 ml/hr 2. Baytril 22.7 mg/ml – 2.75 ml IV SID 3. Cerenia 10 mg/ml – 0.65 ml IV x5 days
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