SUSHI – 35993
Safe - 8-3-2018 Brooklyn
SUSHI – 35993
Care Center Location: Brooklyn; ZIP Code From: 11207; Intake Type: Agency
Medical Behavior: Blue; Age: 10 years; Sex: Male; Weight: 5.38 lbs
Vet Notes: 12:55 PM-H: Intake on 7/27. Honking cough, dental disease and cataracts noted. Given Butorpahol and started on Clavamox.S: BARH. Ate a small amount of food. Occasional cough. No svd.CRT: <2s. Gums: pink, moistEyes: Cataracts OU with ocular crusting OD Ears: Unremarkable AU. Nasal Cavity: No nasal discharge. Oral Cavity: Severe dental/periodontal disease PLN: WNL Heart: No murmurs or arrhythmias. Pulses strong and synchronous. Lungs: Eupneic, lungs clear. No crackles or wheezes bilaterally. No cough elicited on tracheal palpation Abd: Soft, non-painful. No palpable masses. No organomegaly appreciated. U/G: MI. No discharge. Musculoskeletal: Ambulatory x 4 with mild to moderate diffuse muscle wasting BCS = 4/9 Integument: Otherwise unremarkable haircoat. Neuro: Appropriate mentation. Full neurologic exam not performed. Rectal: Not performed. Externally normal. Assessment:1) Coughing-given age, breed and type of cough, top differential would be tracheal collapse. Cannot r/o other upper airway diseases such as neoplasia. Also cannot r/o lower airway disease (bronchitis, neoplasia less likely pneumonia, CHF). 2) Dental Disease. 3) Cataracts 4) Geriactric Prognosis: Guarded Plan: Down to chest/neck radiographs and BW tomorrow Continue Clavamox 13.75 mg/kg PO BID until 8/6. Monitor cough- if worsens, consider continuing butorphanol
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