LUCKY MAN – 24514
Safe - 4-17-2018 Manhattan
LUCKY MAN – 24514
Location: Manhattan, Intake Date: 4/5/18, Intake Type: Stray
Medical Behavior: Blue, Sex: Male, Age: 15 years, Weight: 11 lbs, Original Location: 10460
DVM Intake Exam; Estimated age: 15; Microchip noted on Intake? n; History : Owner in the hospital; Subjective: Cannot walk on hind-end (weakness), urinated while being held. Upon handling began coughing and became dyspnic ; Observed Behavior – anxious; Objective ; T = -; P = 120; R = 40; BCS = 6.5/9; Coughing on examination when excited ; Tracheal palpation negative for cough reflex; EENT: Bilateral cataracts, bilateral central neo vascularisation of the cornea, No Fluorscene uptake in both eyes, OD scarring on the dorsal central aspect of the cornea, ears brown debris and erythema, no nasal or ocular discharge noted; Oral Exam: Endentulous ; PLN: No enlargements noted; H/L: Grade 5/6 Heart murmur on right and left side, NSR, CRT < 2, Lungs clear, eupnic; ABD: Non painful, no masses palpated; U/G: Intact male, 2 cm round perinanal/anal mass; MSI: Non ambulatory on the hind-end (paresis vs paralysis), Mild adduction of the tarsal joints, placing reflex present, skin free of parasites, no masses noted, healthy hair coat; CNS: Mentation appropriate – no signs of neurologic abnormalities; Rectal: round anal/perianal mass (2 cm in diameter); Assessment: 1) Grade 5 Heart Murmur, coughing – ddx mitral valve disease 2) Hind-limb paralysis vs paresis 3) Bilateral Cataracts – incipient 4) Edentulous 5) Peri-anal mass 6) Moderate Otitis externa 7) Urinary incontience suspected 8) Obsesity – grade 6.5/9 Prognosis: Poor Plan: 1) Sedated Chest X-rays V/D and Lateral – 0.2 mg/kg Butorphanol, 0.2 mg/kg Midazolam IM 2) CBC/Chemistry Medications 3) Based on xray results +/- Benazapril PO 0.2 mg/lb PO BID for 7 days, +/- Furosemide 2mg/kg PO BID 7 days 4) Osurnia application in both ears once only 5) Apply erythromycin ointment to both eyes for 1 weeks BID ***RECOMMEND referral to cardiologist for a thoracic ultrasound plus biospy of perinall mass and BNP SURGERY: Permanent waiver due to age CBC – Mild neutrophilia 11.78 – inflammatory response Chem – Mild elevation in BUN (28) – dehydration vs muscle wasting vs diet A- Unremarkable P – Recheck CBC/CHEM in 1 month S/O – V/D and Lateral Chest – Cardiomegaly – right and left atrial enlargement with elevation of the trachea. Lungs appear to have a diffuse interstitial pattern. Assessment – Ddx – Cardiac Heart Failure – suspect mitral valve disease (CDVD)with secondary pulmonary edema ;R/O – primary pulmonary disease vs metastatic disease vs pneumonia ;Plan; – Furosemide 2mg/kg BID PO for 7 days – RECOMMEND REPEATING XRAYS in 7 days to recheck for improvementin thoracic xrays; – Benazepril 0.4 mg/kg BID PO for 7 days ;RECOMMEND FULL CARDIAC REFERRAL with a CARDIAC ULTRASOUND and BNP ; Rx RECOMMENDATIONS: Pemobendan
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