NELLY – A1121607

NELLY – A1121607

**NEEDS PLACEMENT BY 6PM TODAY 08/11/17**

FEMALE, WHITE / TAN, SHIH TZU MIX, 8 yrs
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition ILLNESS Intake Date 08/11/2017, From NY 11207, DueOut Date 08/14/2017,

Medical Behavior Evaluation YELLOW
Medical Summary DVM Intake Exam Estimated age: 8 years Microchip noted on Intake? negative History : stray Subjective: QARH Observed Behavior -Growled when physically manipulated but likely due to pain  Objective P = wnl R = wnl BCS 4/9 EENT: severe mucoid d/c ou, no nasal discharge, mild yellow waxy debris au Oral Exam: severe dental disease and prognathism PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic ABD: Non painful, no masses palpated U/G: FI, foul smelling urine with pus in it, no MGTs MSI: paraparesis, CP decreased in all 4 limbs. Able to stand and walk a few steps on her own but she is weak. MCS 1.5/3 especially with muscle wasting in the back legs, skin free of parasites, no masses noted, urine scalding with urine soaked hindend CNS: parapareis see above. Unable to elicit any pain in the neck of spine but growls when she is picked up. Assessment: Paraparesis Cachexia in HL Pain-unable to locate location Severe dental disease KCS Vomited bile during PE Urine scalding Unkempt haircoat Elevated liver enzymes Elevated BUN Suspect pyometra with vulvar d/c Hypercholesterolemia Hyperglobulinemia Hyperphosphatemia Hyperbilirubinemia Hyponatremia Hyperkalemia Hypochloremia Plan: CBC-monocytosis 4.09 (0.16-1.12), neutropenia 0.36 (2.95-11.64), eosinopenia 0.04 (0.06-1.23), thrombocytopenia 16 (146-484) Chemistry-high ALP 358 (23-212), high BUN 97 (7-27), unable to to read creat, hypercholesterolemia 469 (110-320), hyperglobulinemia 5.4 (2.5-4.5), hyperphospatemia 8.4 (2.5-6.8), hyperbilirubinemia 1.7 (0-0.9), hyperproteinemia 8.3 (5.2-8.2), hyponatremia 130 (144-160), hyperkalemia 6.2 (3.5-5.8), hypochloremia 95 (109-122) 2 view AXR-soft tissue tubular structure between the bladder and the colon seen on lateral, not seen on VD. no other abnormalities noted CTM while at BACC Place IVC and start on LRS @ 120ml/kg/day Rec NH placement ASAP for pyometra surgery Baytril 10mg/kg IV SID Prognosis: fair to poor SURGERY: temporary waiver for surgery due to illness
Weight 8.4

 

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