PJ – 29962
Urgent - Brooklyn
SUPER URGENT 06/03/18
PJ – 29962
Care Center Location: Brooklyn; ZIP Code From: 11212
Intake type: Owner surrender; Medical Behavior: Blue; Age: 8 years; Sex: Neutered
male; Weight: 18 lbs
DVM Intake Exam: Estimated age: 6 years Microchip noted on Intake? Yes. History : Owner surrender- noted to have medical issues (but not specific in note) Subjective: BARH. Intermittently coughing. Mild sneezing. No vd. Observed Behavior – Nervous, but allows all handling. Objective: P = wnl R = wnl BCS 6/9 EENT: Moderate mucopurulent discharge OS, ears clean, mild serous nasal discharge Oral Exam: mild to moderate dental tartar PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Mild to moderate stertor, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: neutered male, no discharge. MSI: Ambulatory x 4, skin free of parasites, matts noted on legs, roughened haircoat CNS: Mentation appropriate – no signs of neurologic abnormalities Rectal: normal externally. Fluorescin Stain negative OS Assessment: 1) Mucopurulent discharge OS- r/o infectious vs trauma/foreign body vs KCS 2) Coughing, Stertor- r/o infectious (CIRDC) vs more chronic cause for coughing (as was noted he has a previous medical condition) such as collapsing trachea (though not a honking cough) vs lower airway disease (bronchitis vs neoplasia vs enlarged heart (from heart disease) compressing trachea). Prognosis: fair Plan: Move to isolation. Start Doxycycline 10mg/kg PO SID x 10 days. Start Neopolybac OU BID x 7 days then recheck. If cough not improving or condition worsening, consider chest radiographs and bloodwork.
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