6/7/2018

[DVM Intake] DVM Intake Exam Estimated age:12y Microchip noted on Intake?n Microchip Number (If Applicable): History :stray, reported polydipsic. anorexic, weak. ate at ACC Subjective:doughy abdomen, increased skin tent. plae pink gums Observed Behavior -docile, lethargic Evidence of Cruelty seen -n Evidence of Trauma seen -n Objective T = P =120 R =wnl BCS 5/9 EENT: aging chanes to eyes, ears clean, no nasal or ocular discharge noted Oral Exam:heavy dental tartar PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: female, did not shave MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat CNS: lethargy Assessment: open. rule out renal dz, daibetes Prognosis:guarded Plan:cbc/chem/t4 SURGERY: Permanent waiver due to age

6/7/2018

[Spay/Neuter Waiver - Age] It is the policy of ACC not to perform surgery on any animal over the age of 8-10 years due to the higher risks incurred in a shelter setting. The veterinarian is hereby issuing a permanent spay/neuter waiver, from the spay/neuter requirements of the City of NY due to the estimated age of this animal. ACC does recommend you consult with your veterinarian to determine if surgical sterilization is appropriate.

6/7/2018

Bg 345 elevated les (likely diabetic hepatopathy) urine dipstick shows glucose >1000, +++ ketones. leukocytes in urine. gave 2 units PZI at 130pm will start on 62.5mg clavamox bid PZI starting tomorrow 1 unit bid 100cc lrs sq bid bg tomorrow AM

6/8/2018

H: Intake on 6/7. Stray, reported polydipsic. anorexic, weak. ate at ACC CBC/Chem/T4: CBC- Mild anemia (Hct 29.5%), mildly regenerative (59.1K), leukocytosis (29.5), Neutrophilia (15.65), Chem- Hyperglycemia (345), mild elevation in BUN (51), Elevation in LES: ALT 529, ALP 180, GGT 5 urine dipstick shows glucose >1000, +++ ketones. leukocytes in urine. Given 2 units PZI at 130pm, started on 1U Prozinc SQ BID S: QAR to BAR. ~5-6% dehydrated. No csvd. Mod amount of formed stool. Large amount of urine in cage. NI in food this morning (ate a small amount of tuna prior to insulin administration) CRT: <2s. Gums: pink, tacky Eyes: Grossly appropriate OU. Ears: Unremarkable AU. Nasal Cavity: No nasal discharge. Oral Cavity: moderate dental tartar/periodontal disease PLN: WNL Heart: Quiet gallop rhyhtym ausculted. Pulses adequate bilaterally Lungs: Eupneic, lungs clear. No crackles or wheezes bilaterally. Abd: Soft, non-painful doughy abdomen. No palpable masses. No organomegaly appreciated. U/G: Normal external genitalia. No discharge. Musculoskeletal: Ambulatory x 4 with no appreciable lameness. BCS = 6/9 Integument: roughened haircoat Neuro: Appropriate mentation. Full neurologic exam not performed. Rectal: Not performed. Externally normal. BG: 429 Since not eating well this morning, only 0.5U prozinc given this morning Assessment: 1) Diabetic Ketosis (DK)- unable to determine if DKA as unable to measure pH on bloodwork. r/o common comorbidites such as UTI/pyelonephritis, pancreatitis, etc. 2) Mildly regenerative anemia- given the minimal regenerative response, cannot r/o causes for non-regenerative anemia (anemia of chronic disease, renal disease <USG not recorded with UA>, neoplasia) vs causes for regenerative anemia (infectious <mycoplasma> vs IMHA <primary v secondary to infectious, medication, vaccine, neoplasia> vs less likely toxin, hemorrhage) 3) Elevated LES r/o diabetic hepatopathy vs cholangiohepatitis vs neoplasia less likely neoplasia 4) Gallop rhythym- r/o secondary to underlying heart disease (HCM)/excessive fluid administration Prognosis: Guarded Plan: Continue 1U Prozinc BID, obtain BG prior to insulin administration- if not eating or if BG<300, do not administer and call Dr. Decrease fluid administration to 40mls SQ BID Added Maropitant 1 mg/kg SQ SID x 3 days, then re-eval Continue Clavamox until 6/16 Seek NH placement- needs AUS, urine culture to further assess for underlying comorbidities for diabetes.

6/9/2018

H: Intake on 6/7. Stray, reported polydipsic. anorexic, weak. ate at ACC CBC/Chem/T4: CBC- Mild anemia (Hct 29.5%), mildly regenerative (59.1K), leukocytosis (29.5), Neutrophilia (15.65), Chem- Hyperglycemia (345), mild elevation in BUN (51), Elevation in LES: ALT 529, ALP 180, GGT 5 urine dipstick shows glucose >1000, +++ ketones. leukocytes in urine. Given 2 units PZI at 130pm, started on 1U Prozinc SQ BID S: QAR to BAR. No csvd. Mod amount of urine. No BM. Most of wet food gone. Hissing and swatting- visual only performed Eyes: Grossly appropriate OU. Ears: Unremarkable AU. Nasal Cavity: No nasal discharge. Lungs: Eupneic U/G: Normal external genitalia. No discharge. Musculoskeletal: Ambulatory x 4 with no appreciable lameness. BCS = 6/9 Integument: roughened haircoat Neuro: Appropriate mentation. Full neurologic exam not performed. Rectal: Not performed. Externally normal. 6/8: AM BG 429 (not eating), gave 0.5 prozinc; PM BG 390 (eating), given 1 U 6/9: AM BG 428 (eating), gave 1U Assessment: 1) Diabetic Ketosis (DK)- unable to determine if DKA as unable to measure pH on bloodwork. r/o common comorbidites such as UTI/pyelonephritis, pancreatitis, etc. 2) Mildly regenerative anemia- given the minimal regenerative response, cannot r/o causes for non-regenerative anemia (anemia of chronic disease, renal disease , neoplasia) vs causes for regenerative anemia (infectious vs IMHA vs less likely toxin, hemorrhage) 3) Elevated LES r/o diabetic hepatopathy vs cholangiohepatitis vs neoplasia less likely neoplasia 4) Gallop rhythym- r/o secondary to underlying heart disease (HCM)/excessive fluid administration Prognosis: Guarded Plan: Continue 1U Prozinc BID, obtain BG prior to insulin administration- if not eating or if BG<300, do not administer and call Dr. Continue LRS SQ administration to 40mls SQ BID Continue Maropitant 1 mg/kg SQ SID x 3 days, then re-eval Continue Clavamox until 6/16 Seek NH placement- needs AUS, urine culture to further assess for underlying comorbidities for diabetes.

6/10/2018

H: Intake on 6/7. Stray, reported polydipsic. anorexic, weak. ate at ACC CBC/Chem/T4: CBC- Mild anemia (Hct 29.5%), mildly regenerative (59.1K), leukocytosis (29.5), Neutrophilia (15.65), Chem- Hyperglycemia (345), mild elevation in BUN (51), Elevation in LES: ALT 529, ALP 180, GGT 5 urine dipstick shows glucose >1000, +++ ketones. leukocytes in urine. Given 2 units PZI at 130pm, started on 1U Prozinc SQ BID S: QAR to BAR. Adequate hydration. No csvd. Mod amount of urine. No BM. Ate half of wet food. Hissing and swatting. CRT: <2s. Gums: pink Eyes: Grossly appropriate OU. Ears: Unremarkable AU. Nasal Cavity: No nasal discharge. Oral Cavity: moderate dental tartar/periodontal disease PLN: WNL Heart: Gallop rhyhtym ausculted with Grade II systolic murmur ausculted. Pulses adequate bilaterally Lungs: Eupneic, lungs clear. No crackles or wheezes bilaterally. Abd: Soft, non-painful doughy abdomen. No palpable masses. No organomegaly appreciated. U/G: Normal external genitalia. No discharge. Musculoskeletal: Ambulatory x 4 with no appreciable lameness. BCS = 6/9 Integument: roughened haircoat Neuro: Appropriate mentation. Full neurologic exam not performed. Rectal: Not performed. Externally normal. Assessment: 1) Diabetic Ketosis (DK)- unable to determine if DKA as unable to measure pH on bloodwork. r/o common comorbidites such as UTI/pyelonephritis, pancreatitis, etc. 2) Mildly regenerative anemia- given the minimal regenerative response, cannot r/o causes for non-regenerative anemia (anemia of chronic disease, renal disease , neoplasia) vs causes for regenerative anemia (infectious vs IMHA vs less likely toxin, hemorrhage) 3) Elevated LES r/o diabetic hepatopathy vs cholangiohepatitis vs neoplasia less likely neoplasia 4) Gallop rhythym + murmur- r/o secondary to underlying heart disease (HCM)/excessive fluid administration 6/8: AM BG 429 (not eating), gave 0.5 prozinc; PM BG 390 (eating), given 1 U 6/9: AM BG 428 (eating), gave 1U; PM BG 429 (not eating), given 0.5U prozinc 6/10 AM BG 511 (did not eat in the moment, but food gone from last night), 1U prozinc given Prognosis: Guarded Plan: Continue 1U Prozinc BID, obtain BG prior to insulin administration- if not eating or if BG<300, do not administer and call Dr. d/c fluids at this time last day maropitant Continue Clavamox until 6/16 Seek NH placement- needs AUS, urine culture to further assess for underlying comorbidities for diabetes.

6/11/2018

H: Intake on 6/7. Stray, reported polydipsic. anorexic, weak. ate at ACC CBC/Chem/T4: CBC- Mild anemia (Hct 29.5%), mildly regenerative (59.1K), leukocytosis (29.5), Neutrophilia (15.65), Chem- Hyperglycemia (345), mild elevation in BUN (51), Elevation in LES: ALT 529, ALP 180, GGT 5 urine dipstick shows glucose >1000, +++ ketones. leukocytes in urine. Given 2 units PZI at 130pm, started on 1U Prozinc SQ BID S: QAR. ~5% dehydrated. No csvd. Mod amount of urine. No BM. Minimally touched food this AM, but was found eating some tuna later. Hissing and swatting. CRT: <2s. Gums: pink Eyes: Grossly appropriate OU. Ears: Unremarkable AU. Nasal Cavity: No nasal discharge. Oral Cavity: moderate dental tartar/periodontal disease PLN: WNL Heart: Gallop rhyhtym ausculted with Grade II systolic murmur ausculted. Pulses adequate bilaterally Lungs: Eupneic, lungs clear. No crackles or wheezes bilaterally. Abd: Soft, non-painful doughy abdomen. No palpable masses. No organomegaly appreciated. U/G: Normal external genitalia. No discharge. Musculoskeletal: Ambulatory x 4 with no appreciable lameness. BCS = 6/9 Integument: roughened haircoat Neuro: Appropriate mentation. Full neurologic exam not performed. Rectal: Not performed. Externally normal. Assessment: 1) Diabetic Ketosis (DK)- unable to determine if DKA as unable to measure pH on bloodwork. r/o common comorbidites such as UTI/pyelonephritis, pancreatitis, etc. 2) Mildly regenerative anemia- given the minimal regenerative response, cannot r/o causes for non-regenerative anemia (anemia of chronic disease, renal disease , neoplasia) vs causes for regenerative anemia (infectious vs IMHA vs less likely toxin, hemorrhage) 3) Elevated LES r/o diabetic hepatopathy vs cholangiohepatitis vs neoplasia less likely neoplasia 4) Gallop rhythym + murmur- r/o secondary to underlying heart disease (HCM)/excessive fluid administration 6/8: AM BG 429 (not eating), gave 0.5 prozinc; PM BG 390 (eating), given 1 U 6/9: AM BG 428 (eating), gave 1U; PM BG 429 (not eating), given 0.5U prozinc 6/10 AM BG 511 (did not eat in the moment, but food gone from last night), 1U prozinc given; PM BG 418 (eating), gave 1U prozinc 6/11 AM BG 610 (ate a small amount of food), 1 U prozinc given Prognosis: Guarded Plan: Continue 1U Prozinc BID, obtain BG prior to insulin administration- if not eating or if BG<300 or BG>600 do not administer and call Dr. - If BG remains >600 will have to increase Prozinc Restart fluids - LRS 30mls SQ BID until 6/14, then re-eval Restart Maropitant 1 mg/kg SQ SID until 6/15 then re-eval Continue Clavamox until 6/16 Schedule repeat CBC/Chem/UA for tomorrow Seek NH placement ASAP- Needs further supportive care (fluids, BG monitoring, GI supportive care- needs regular insulin to bring glucose down to normal before starting longer acting insulin) - also needs AUS, urine culture to further assess for underlying comorbidities for diabetes.

6/12/2018

H: Intake on 6/7. Stray, reported polydipsic. anorexic, weak. ate at ACC CBC/Chem/T4: CBC- Mild anemia (Hct 29.5%), mildly regenerative (59.1K), leukocytosis (29.5), Neutrophilia (15.65), Chem- Hyperglycemia (345), mild elevation in BUN (51), Elevation in LES: ALT 529, ALP 180, GGT 5 urine dipstick shows glucose >1000, +++ ketones. leukocytes in urine. Given 2 units PZI at 130pm, started on 1U Prozinc SQ BID S: QAR. ~5-6% dehydrated. Small amount of food eaten. Sitting in box, so unable to assess urine. Hissing and trying to swat, but seems less energetic today compared to other days CRT: <2s. Gums: pink Eyes: Grossly appropriate OU. Ears: Unremarkable AU. Nasal Cavity: No nasal discharge. Oral Cavity: moderate dental tartar/periodontal disease PLN: WNL Heart: Gallop rhyhtym ausculted. Lungs: Eupneic, lungs clear. No crackles or wheezes bilaterally. Abd: Soft, non-painful doughy abdomen. No palpable masses. No organomegaly appreciated. U/G: Normal external genitalia. No discharge. Musculoskeletal: Ambulatory x 4 with no appreciable lameness. BCS = 6/9 Integument: roughened haircoat Neuro: Appropriate mentation. Full neurologic exam not performed. Rectal: Not performed. Externally normal. CBC: Moderate to severe anemia (Hct down to 16.1 from 29.5 on intake), now moderately regenerative (Retic 174K), Leukocytosis (28.46), Neutrophilia (21.92), Monocytosis (2.22) Chem: Hyperglycemia (478), Mild increase in BUN (55), moderate hypokalemia (2.5), ALT 182 (improved), ALKP 193 UA: USG 1.020, Ketone negative Assessment: 1) Diabetic Mellitus (ketones resolved)- Patient currently not eating well and continues to be dehydrated - needs more intensive supportive care (with gallop rhythm, will need to be monitored closely on IVF) r/o common comorbidites such as UTI/pyelonephritis, pancreatitis, etc. 2) Anemia, regenerative- top differentials given that she is likely an outside cat would be infectious (mycoplasma haemofelis) vs IMHA (primary v secondary to neoplasia, vaccines, new medication) vs less likely hemorrhage (no obvious source identified). 3) Elevated LES (improving) r/o diabetic hepatopathy vs cholangiohepatitis vs neoplasia less likely neoplasia 4) Gallop rhythm +/- murmur- r/o secondary to underlying heart disease (HCM) vs physiologic 5) Hypokalemia- likely secondary to insulin administration (transcellular shift) though cannot r/o other causes such as renal disease 6/8: AM BG 429 (not eating), gave 0.5 prozinc; PM BG 390 (eating), given 1 U 6/9: AM BG 428 (eating), gave 1U; PM BG 429 (not eating), given 0.5U prozinc 6/10 AM BG 511 (did not eat in the moment, but food gone from last night), 1U prozinc given; PM BG 418 (eating), gave 1U prozinc 6/11 AM BG 610 (ate a small amount of food), 1 U prozinc given; PM BG 471 (not eating) 0.5U prozinc given 6.12 AM BG 534 (not eating), 1U prozinc given Prognosis: Guarded Plan: Start Doxycycline 10mg/kg PO SID x 14 days for possible mycoplasma- recommend further diagnostics (Comprehensive CBC w/path review, Coombs test, mycoplasma PCR) to further assess for cause of anemia Continue 1U Prozinc BID, obtain BG prior to insulin administration- if not eating or if BG<300 or BG>600 do not administer and call Dr. - If BG remains >600 will have to increase Prozinc Continue LRS 30mls SQ BID until 6/14, then re-eval Continue Maropitant 1 mg/kg SQ SID until 6/15 then re-eval Continue Clavamox until 6/16 Seek NH placement ASAP- Needs further medical care (fluids, BG monitoring, nutritional support, GI supportive care; needs regular insulin <intermittent injection v CRI> to bring glucose down to normal before starting longer acting insulin) - also needs AUS, urine culture to further assess for underlying comorbidities for diabetes.

6/12/2018

Dispensed Clavamox drops 1 cc BID x 6 days