9/17/2018

[DVM Intake] DVM Intake Exam Estimated age: 5-6 months Microchip noted on Intake? No Microchip Number (If Applicable): Subjective: BAR Observed Behavior -Nervous but friendly, allowed all handling Evidence of Cruelty seen -Possibly, coat is painted blue Evidence of Trauma seen -No Objective T = P =220 bpm R =eup BCS 4/9 EENT: Eyes clear, moderate brown thick dried ear mite debris AU, no nasal or ocular discharge noted Oral Exam: Clean teeth PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: F/I,no obvious spay scar or tattoo MSI: Ambulatory x 4, skin free of parasites, no masses noted, majority of her coat is blue-looks like paint, mild erythema with crusting on chin CNS: Mentation overall appropriate, intermittently seems weak vs. ataxic in hind limbs but not consistent and no pain noted Rectal: Clean externally Assessment: Blue coat-r/o paint vs. other Ear mites Intermittent weakness/ataxia in hind limbs-r/o from possible pain (if has lead in it can be toxic) Prognosis: Good Plan: Cleaned ears AU Gave ivermectin 0.06 mL SQ Sedation: butorphanol 0.3 mg/kg IM, dexmedetomidine 8 mcg/kg IM Bathe her with Dawn soap Recheck tomorrow Recheck ears in 2 weeks SURGERY: Okay for surgery

9/18/2018

History of being sprayed with spray paint S/O - pt attention seeks and is very sweet. QARH in kennel. Food bowl full. Does not appear to be very active - brought out of kennel and did not move alot on the ground - lethargy? Objective T = 100 P = 258 R = 40 BCS = 4/9 EENT: Eyes clear, ears clean, no nasal or ocular discharge noted Oral Exam: teeth in good cont - mild hyperemic gums PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated MSI: Ambulatory x 4 although is not very active - lethargy vs neurological skin free of parasites, no masses noted, healthy hair coat CNS: Tremors Rectal: externally normal Assessment - attention seeking and gentle - lethargic/inactive in kennel - Moderate tachycardia at rest - Mild tachypnea at rest - Tremors Rule out - toxicity vs metabolic disorder Prognosis: Fair Plan: - Place an IVC and LRS @ 7 ml/hr (2 x maintenance) for 24 hrs - Schedule for a CBC/Chem tomorrow

9/19/2018

S/O - pt eating and drinking. Still mildly lethargic and not very active Objective T = - P = 240 R = 60 CRT 2 <2 mmb pink EENT - mild serous nasal discharge, no ocular discharge. Black debris; pruritic OU PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated MSI: Full body tremors CNS: Quiet, mild paresis Rectal: externally normal CBC/Chem Mild anemia, mild monocytosis Mild elevation in ALT Assessment - Pt eating and drinking, attention seeking - very gentle and sweet - Tremors - Tachycardia and tachypnea - Paresis/lethargy DIFFERENTIAL DIAGNOSIS - Toxicity vs other Prognosis: Fair Plan: - Continue on current plan - Reduce fluids to 5ml/hr - Monitor for changes in critical signs RECOMMEND: Seek Immediate placement at a VETERINARY HOSPITAL

9/21/2018

SO BAR, very friendly! Allows all handling. Currently on 5ml/hr LRS fluids. Euhydrated EN -- eyes and nose are clear with no discharge. Oral -- normal kitten dentition. Abd -- soft. no masses palpated. A hx of being spray painted and having tachycardia, tremors -- resolved P ok to remove IV catheter monitor for remainder of day in medial, move to adoptions if P continues to do well.

Upon intake, Marina allowed all handling. She was tense and stress meowed. She allowed herself to be held. Her breathing was labored and staccato-like.