JAY JAY – A1111689

JAY JAY – A1111689

***Needs Immediate Vet Care***

MALE, WHITE / CHOCOLATE, COCKER SPAN MIX, 8 yrs
OWNER SUR – AVAILABLE, HOLD RELEASED Reason PET HEALTH
Intake condition EXAM REQ Intake Date 05/11/2017, From NY 10456, DueOut Date 05/11/2017,

Medical Behavior Evaluation GREEN
Initial Exam (5/11/17)  DVM Intake Exam; Estimated age: Reported 8 years, exam is consistent with this; Microchip noted on Intake?   Scanned positive; History : Surrendered.  Pt has been lethargic, vomiting and having diarrhea for 2-3 weeks. No appetite – the last time he ate anything was about 1 week ago. Pt also has an ear infection. He was perfectly fine up until 2 weeks ago with good energy levels and a good appetite. No other pets in the house.; Subjective: Calm, allows all handling.; Objective  ; Tachypneic.  BCS 3.5/9, MMs pale/white.; EENT:  Mild epiphora OU. Moderate waxy discharge and hyperkeratosis AU. Serous nasal discharge.; Oral Exam:  Moderate tartar; PLN:  No enlargements noted; H/L:  NSR, NMA, CRT < 2,    Tachypneic, lungs quiet; ABD:  Soft, non painful, no masses palpated; U/G:  Male neutered; MSI:  Ambulatory x 4, skin free of parasites, long nails.; CNS:  Quiet but seems aware of surroundings.; CBC: Anemia (Hct 28.8%), WBC 40.7 K/ul, neutrophilia 38.4 K/ul, lymphocytopenia 0.68, monocytosis 1.52, eosinopenia 0.02; Chemistry: Severely elevated BUN (>130), severely elevated phos (>16.1). Creat and Ca didn’t read. T protein 9, hypoalbuminemia (2.2) but hyperglobulinemia (6.8), mildly elevated cholesterol (335); Abd and chest rads

Assessment

1. Dehydration and anemic – once you correct for dehydration, pt will be more anemic
2. Severe azotemia, hyperphosphatemia, hyperglobulinemia, anemia – R/O pyelonephritis vs. lepto vs. primary renal dz and secondary infection vs. otherPlan

1. Place IVC and start LRS at 75 ml/hr
2. Ampicillin 250 mg/ml 1.3 ml IV q6-8 hours x4 days
3. Baytril 22.7 mg/ml inj 4.5 ml diluted in 45-50 ml NaCl (NOT LRS) given IV slowly over 10 min – q24
4. Famotidine 1.1 ml IV q24 x5 days
5. Send out lepto titers
6. Recommend abd ultrasound

Prognosis: Fair (with appropriate treatment) to guarded

PROFILE:

Basic: Jay Jay is an 8 year old neutered American cocker spaniel. His owner got him as a gift and has had him for about 8 years. The owners are surrendering Jay Jay because he hasn’t been feeling well. He hasn’t had an appetite in about 1.5 weeks. The last time he was at the vet was 3 weeks ago for this problem but he did not receive treatment.

Socialization: Jay Jay is little shy around strangers at first but then is friendly and playful. He has spent time around children ages 1 year and up and is playful and relaxed with them. He plays exuberantly with both children and adults. He hasn’t spent time with other dogs much but plays with them exuberantly. He has not spent time around other pets and does not have a bite history.

Socialization: Jay Jay is well-behaved. He gets nervous during storms or loud noises. When he is eating, or chewing on something he isn’t bothered when someone takes things out of his mouth, or away from him. He isn’t bothered when someone pushes him off furniture, or holds him. He loves getting baths and being brushed. He will let his owner touch his feet, and gets his nails trimmed at the groomers. He isn’t bothered when he is disturbed while sleeping. He will bark when someone is at the door, but then relaxes once they are inside and he isn’t bothered when a stranger approaches his family member.

For New Family: Jay Jay is described as friendly, affectionate, playful, and sometimes shy. His energy level is medium. He will follow everyone around the house at home. He loves to play tug with rope toys, and also loves chew bones. He has been kept mostly indoors and sleeps in his dog bed in his owner’s room. He ears both wet and dry food. He is very housetrained, and is trained to use a pad at home for when his owners can’t walk him. Outside, he will go on the grass or cement. He is well-behaved when left alone, and knows “sit, come, stay” commands in both Spanish and English!! For exercise he loves to go for brisk walks and does not pull on the leash. When he is off leash he will wander a little, but comes when called.

During intake Jay Jay allowed all handling and collaring. He was alert, but was breathing heavily and was lethargic.

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