BILL – 14713
Safe - 11-27-2017 Brooklyn
SAFE 11/27/17 **NEEDS TRANSFER TO VET BY 6PM! Beautiful Orange Tabby BILL With Possible Head Trauma NEEDS YOU TODAY!**
Brooklyn Center
Bill 14713 – 3 yr. old male orange tabby:
Vet Notes: 11:15 AM
DVM Intake Exam
Estimated age: 3 yr
Microchip noted on Intake? No
History : Found on street, unknown history
Subjective:
Observed Behavior –
Evidence of Cruelty seen –
Evidence of Trauma seen – Possibly
Objective
T = 98 (on intake)
P = 150
R = 40
BCS 2.5/5
EENT: Eyes clear, PLR present, decreased menace, ears clean, no nasal or ocular discharge noted
Oral Exam: Clean teeth, mm pink, dirt on lower incisors
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated, soft medium size bladder palpated
U/G: MI, sst
MSI: Nonambulatory x 4, withdrawal present x 4, p able to sit in sternal recumbancy, skin free of parasites, no masses noted, dusty/dirt haircoat
CNS: Mentation inappropriate – laterally recumbent, but able to sit in sternal with help, growls when examining mouth
Rectal: Not performed, anal tone present during temp
Assessment: Neurologically inappropriate- r/o head trauma vs. other
Prognosis: Pending response to tx- if responds over next 24 hours- fair to good
If does not repond- poor
Plan:
Full body x-rays- no fractures seen, normal neck, spine and pelvis, bladder present, triangular/square abnormal shapes in stomach- r/o previous meal
CBC/chem/lytes- unremarkable
IVC, 83mL fluid bolus followed by 1.5x maintenance fluids
Buprenex .015mg/kg IV
Attempt placement with New Hope for additional supportive care overnight vs. EHR
Hold on vaccines etc. for now
Recheck temp after fluids bolus 100.4F
SURGERY:
Temporary waiver due to possible head trauma
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View all entries in: Safe Cats 2017-11