AIKO – 36002
Safe - 7-30-2018 Brooklyn
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AIKO – 36002
Care Center Location: Brooklyn;ZIP Code From: 11212; Intake Type: Owner
Surrender;Medical Behavior: Blue; Age: 12 years; Sex: Neutered; Weight: 28 lbs
Vet Notes: 5:47 PM– H: Intake on 7/28. Noted to leak urine and occasionally vomit. Hematology- neutrophilia, monocytosis, lymphopenia, eosinopenia. Chemistry-
Mild-moderately elevated BUN 47 (7-27 mg/dL) Mild hypochloremia 106 (109-122 mmol/L) Mildly elevated ALT 221 (10-25 U/L) Moderately elevated ALP 1,275 (23-212 U/L) Mildly elevated GGT 28 (0-11 U/L) Total T4 1.4 (1-4 ug/dL) STT- 14mm/min OD 8mm/min OS S: QARH. No csvd. NI in regular food, but ate tuna readily. No eliminations in cage. CRT: <2s. Gums: pink, moist Eyes: Corneal stippling with moderate mucoid discharge OU Ears: mild to moderate ceruminous discharge. Nasal Cavity: No nasal discharge. Oral Cavity: moderate dental tartar/periodontal disease PLN: WNL Heart: No murmurs or arrhythmias. Pulses strong and synchronous. Lungs: Eupneic, lungs clear. No crackles or wheezes bilaterally. Abd: Moderate to severely distended abdomen (pot belly); Soft, non-painful. No palpable masses. No organomegaly appreciated. U/G: MN. No discharge. Musculoskeletal: Ambulatory x 4 with no appreciable lameness. BCS = 8/9 Integument: Multiple areas of skin bruising noted throughout body; unkempt haircoat with areas of alopecia Neuro: Appropriate mentation. Full neurologic exam not performed. Rectal: Not performed. Externally normal. Assessment: 1) Decreased tear production- suspect mild to moderate kcs 2) Elevated LES (severely elevated ALKP)- given patient’s appearance (pot belly, alopecia and areas of skin bruising/necrosis, history of frequent urination), top differential would be Cushings disease. However, with other LES being mildly elevated, cannot r/o primary liver/cholestatic disease (cholangiohepatitis/cholangitis, neoplasia, toxin, vacoular hepatopathy). Plan: Start Optimmune OU BID Monitor appetite- if continues not to eat well add SQF and cerenia CTM in Medical Seek NH placement- recommend LDDS, AUS +/- IM Consult
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