FIVEL – 28347

FIVEL – 28347

Location: Brooklyn,  Intake Date: 5/17/18,  Intake Type: Stray

Medical Behavior: Green,  Sex: Male,  Age: 10 years,  Weight: 5 lbs

Original Location: 11422

H: Intake on 5/17- noted to be underweight, dental disease and moist dermatitis and causeous material around scrotal region; Given one injection of rimadyl 7.5mg sq; and started on clavamox 32.5mg bid x 14d; CBC/Chem; CBC- moderate to severe leukocytosis (25.78K), Neutrophilia (21.2K); Chem- BUN 60, Creat 1.6 (mild azotemia), hypercalcemia (13.7); S: QAR to BAR. Food minimally touched this morning, but ate well last night. Urinated moderate amount last night.   T 101.2F; P 140bpm; R 28bpm; Exam: CRT: <2s. Gums: pink, moist; Eyes: Grossly appropriate OU.  Ears: Unremarkable AU.  Nasal Cavity: No nasal discharge.   Oral Cavity: moderate to severe tartar/periodontal disease ; PLN: WNL; Heart: No murmurs or arrhythmias. Pulses strong and synchronous.; Lungs: Eupneic, lungs clear. No crackles or wheezes bilaterally.  Abd: Soft, non-painful. No palpable masses. No organomegaly appreciated.  U/G: See Integument section- intact male; Musculoskeletal: Ambulatory x 4 with no appreciable lameness; moderate to severe cachexia/diffuse muscle wasting noted ; BCS = 2/9; Integument: Moist, ulcerative dermatitis noted within the inguinal region- the scrotal tissue appears necrotic with mild purulent discharge noted. The fur appears matted around the perineal region. A live maggot was noted on the table during exam, but no further larvae noted.  Neuro: Appropriate mentation. Full neurologic exam not performed.  Rectal: Not performed. Externally normal.  Assessment; 1) Thin/Cachexia  2) Ulcerative dermatitis with areas of necrosis noted (perineum/scrotum/inguinal region), maggot noted during exam- suspect secondary to severe urine/fecal scald combined with matting and inability to groom area–concern for worsening necrosis, and the potential for sepsis/SIRS  3) Dental Disease  4) Azotemia (mild) – r/o pre-renal vs renal ( CKD, acute on chronic renal disease- infectious, toxin, neoplasia) vs post -renal (ureteroliths)  5) Hypercalcemia – r/o true hypercalcemia vs spurious  Prognosis: Fair to guarded ; Plan:  Sedated with Dexmedetomedine 5mcg/kg IV + Buprenorphine 0.02 mg/kg IV once; Applied Lidocaine Splash Block to area; The area of the perineum was clipped of fur/matts, cleaned with chlorhexidine scrub and sterile saline, then flushed thoroughly with sterile saline. ; SSD was applied to the area of ulceration; Continue Clavamox; Added Enrofloxacin 10 mg/kg IM SID x 7 days, then re-eval; Added Buprenorphine 0.02mg/kg IM BID x 5 days, then re-eval ; Given one tablet of capstar; Recommend AUS, UA +/- UC, iCa once placed

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