PRADA – 11577
Safe - 11-6-2017 Brooklyn Rescue: Second Chance Rescue Please honor your pledges: http://www.nycsecondchancerescue.org/donate/
PRADA – 11577
**NEEDS PLACEMENT BY 6PM TODAY, 11/06/17**
Intake Date: 11/3/17 Intake Type: Owner Surrender
Medical Behavior: Green Sex: Spayed Age: 5 years
Weight: 49.8 lbs
DVM Intake Exam : Estimated age: ~4-6 years Microchip noted on Intake? negative History : o/s-reported to have vulvar d/c Subjective: QAR, ~7% dehydrated (skin tent, dry mm, sunken eyes) Observed Behavior – very sweet. Easily handleable. Did well for all medical handling and procedures Evidence of Cruelty seen – yes Evidence of Trauma seen – no Objective : P = wnl R = eupneic BCS 2/9 EENT: Eyes clear, ears have severe thick brown waxy debris with a foul odor, no nasal discharge noted Oral Exam: adult dentition with moderate dental tartar, no oral lesions noted PLN: No enlargements noted H/L: NSR, Grade 2/6 HM, CRT < 2, Lungs clear, eupneic ABD: tense, unable to deeply palpate
U/G: FI, severe purulent vulvar d/c with edematous vulva, no MGTs but has developed mammae MSI: Ambulatory x 4 but weak, skin free of parasites, no masses noted, dull, greasy, and flaky hair coat, overgrown nails but none embedded, mild pododermatitis x4 CNS: mentation appropriate – no signs of neurologic abnormalities Assessment: UTI with abnormality of bladder Dehydrated, Emaciated, Dental disease, Grade 2/6 HM, Overgrown nails, Pododermatitis x4 Plan: Continue to monitor while at BACC, Place IVC
Start LRS 100ml/kg/day-monitor heart rate/murmur closely, Start baytril 10mg/kg IV BID for possible sepsis until 11/17, Start hydromorphone 0.1mg/kg IV BID post op until 11/6, Lateral AXR-very large soft tissue opaque tubular structure in caudal abdomen, Exploratory laparotomy and spay, Flagged for cruelty-took pictures, Trimmed nails
CBC-severe leukocytosis 36.88 (5.05-16.76) with monocytosis 3.64 (0.16-1.12) and severe neutrophilia 31.11 (2.95-11.64), eosinopenia 0.04 (0.06-1.23), anemia 21.4 (37.3-61.7)
Chem-hypoalbuminemia 2 (2.3-4), hyperglobulinemia 4.9 (2.5-4.5) UA-SpGr=1.018 refractometer. Dipstick – bilirubinuria ++, blood 250, protein ++, pH, 6, USG 1.005, leukocytes 500 Move to medical for daily rechecks Rec cardio consult Clean ears Start on tresaderm AU BID x14d until 11/17 Start claxamox 13.75mg/kg PO BID x14d until 11/17
Prognosis: Guarded pre-op-if does well after surgery then px is good
11/06/17: Rec end of day deadline since not urinating-medical emergency; Will try to walk again in an hour, if not urinating will sedate and attempt to pass a urinary catheter; Rec AUS of bladder to look for neoplasia vs other abnormalities
A Little Bit About Me…
Let’s get to know each other a bit more…
Basic Information: Prada came in as an owner surrender as he is unable to properly care for her any longer. She is a 4 year old, gray, white and tan female, who was not spayed prior to coming into the shelter. She came in with medical conditions that will need attention and has not seen a vet recently.
Previously lived with: In home with owner
How is this dog around strangers? Prada is friendly and outgoing with strangers. She approaches and will elicit attention.
How is this dog around children? Prada has lived with children before and is respectful and tolerant of them. They play well together without any conflicts.
How is this dog around other dogs? Prada is playful and relaxed around other dogs.
How is this dog around cats? Prada is has spent time around family members cats and is tolerant of them.
Resource guarding: Prada has no resource guarding behavior.
Bite history: Prada has no bite history
Energy level/descriptors: Medium
Has this dog ever had any medical issues? Yes
Medical Notes Prada came into BACC with a pyo. infection and she was bloated. She was underweight and had stopped eating two week prior to being surrendered.
For a New Family to Know Prada is described as being friendly, affectionate, and playful. Her owner stated she allows for bathing and grooming, but she will struggle to get out of the tub. She dose not allow her nails to be trimmed. She will alert bark when someone approaches their house or yard. She will follow her family around when they are home and likes to play with stuffed toys, squeaky toys, and chew bones. She has been an indoor dog, sleeps wherever, and eats both wet and dry food. She is house trained to go outside and rarely has accidents inside. She is well behaved when left alone in the house and has not been crate trained. She knows commands sit, come, down and stay. She walks off leash and stays near her owner.
Prada was very lethargic in the office and did not move from her spot. She allowed counselor to collar her with ease.
My medical notes are…
11/03/17 Vet Notes :SURGERY: will have surgery today for pyometra
Recheck post-spay (suspected pyometra on intake, new working diagnosis is cystitis, UTI)
S/O: QAR. ~5-8% dehydration. Eating and drinking well. Allows all handling. Attention seeking EENT: Eyes clear, no ocular discharge, minor defect of upper left eyelid, no nasal discharge, pale pink tacky mm, moderate dental staining/wear, mild tartar, no gingivitis, moderate brown debris AU HL: Grade 1-2 heart murmur, lungs clear ABD: not palpated due to recent abdominal sx INTEG: Callous at elbows and hocks, generalized dry hair coat, mild pododermatitis; incision healing well – CDI, no signs of infection MS: Ambulatory x 4 UG: Spayed, mild mucoid vaginal discharge A: Middle aged to senior pet, doing well post spay. On treatment for UTI/cystitis, bladder was markedly inflamed on observation P: Continue with current treatment and monitoring plan. Adding rimadyl 50mg PO q12 x 5 days. Good prognosis with response to treatment
11/04/17 Vet Notes : SPAY SX – Green Linear Tattoo Placed on Midline
Additional Comments: Initially, oozing much blood on skin/ SQ incision. Abnormal skin – thin and crepe-like. SQ has dark color. Abdominal exposure- bladder extremely distended and very angry/ markedly inflamed. Large incision to visualize and exteriorize. Urine removed by sterile means – urine very cloudy and foul smelling. Bladder wall markedly thickened and hard- approx 1 cm thickness after urine removal. Overall explore– Omentum – yellow tinge and inflamed. Mild- mod amount serous peritoneal fluid. Lumbar lymph nodes enlarged. Nodular hyperplasia on spleen. Liver – no masses. Intestines – NSF. Stomach – distended with food and gas. Uterus – consistent with geriatric age but not in heat or distended.
A) No pyometra. Marked cystitis – r/o severe UTI vs underlying bladder dz (neoplasia, inflamm/ immune). Marked leukocytosis. Dehydration. Heart murmur. P) IV fluids run during sx. Discontinue overnight – concern with heart murmur and unsure if able to urinate ok. Keep catheter and restart fluids in the AM. Monitor for urination. Cont abs – baytril and clavamox. Cont pain meds. Prognosis: Guarded to poor.
Addendum: Vomited when waking before extubation. Still recumbant but responsive and moving legs at 19:45 PM. T= 92.7. Placed heating pad for 1/2 hour.
Details on my behavior are…
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