KAT LEE – 16993

KAT LEE – 16993

13 yr. spayed, stray, 10 pounds

DVM Intake Exam; Estimated age: 14 yo; Microchip noted on Intake? yes ; Microchip Number (If Applicable):(464F385D52); History : Stray — found outside; Subjective: Quiet/Dull on exam. Will perk up with attention (minimal); Observed Behavior – friendly when alert; Objective ; P = 88; R = 28; BCS 3/9; EENT: Eyes mildly cloudly OU, dry brown crusty periocular debris OU, ears mild brown debris AU, Left-sided unilateral mucopurulent nasal discharge (brown); Oral Exam: severe dental/periodontal disease; PLN: No enlargements noted; H/L: No murmurs auscultated, lung sounds are decreased in caudal sectors (right worse than left). ABD: Non painful, no masses palpated U/G: spayed female; MSI: Severe weakness in hindlimbs, grade 2/4 luxating patella on left, grade 3/4 luxating patella on right, skin free of parasites, numerous skin masses along dorsum (sebaceous cysts) CNS: Dull at times, severe weakness/paraparesis in hindlimbs; Rectal: signficant anal gland impaction (bilateral)– easily expressed (brown pasty contents) — decreased anal tone.  Rads (lateral and VD whole body): bronchointerstitial lung pattern throughout lung fields with caudal regions most severely affected (mild to moderate old dog changes). No other significant findings.; CBC/CHEM:  Inflammatory leukogram (elevated WBC 34.82, elevated neutrophil 30.56, elevated monocytes 1.84) Glucose elevated (214); Calcium low (7.4); Potassium low (3.1); Chloride low (101); ALT elevated (152); ALP elevated (416); GGT elevated (23); Amylase low (434); Assessment: Old age with potential long-standing lumbar IVDD.  Prognosis: guarded  Plan: Iv fluids started along with 0.5ml Dexamethasone (2mg/ml) IV and 0.25 ml B-12 vitamin complex IV and 0.3ml enrofloxacin (100mg/ml).  0.3ml enrofloxacin (100mg/ml) IM q24 for 7 days to be continued along with IV fluids.  Continued monitoring while at BACC. Humane euthanasia for geriatric decline recommended if no return to owner or New Hope placement.

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