BILL – 21008
Safe - 3-3-2018 Brooklyn
SAFE 3/3/18 **6-MONTH QUARANTINE NEEDED FOR SUPER FRIENDLY KITTY, BILL!**
Due to bite wounds, Bill will need to be quarantined per DOH and kept indoors for 6 months;
For the first 45 days, Bill will need to reside in a vet hospital OR receive weekly veterinary exams for that period.
Thereafter, Bill will need to receive monthly vet health exams for the remainder of 6 months. BILL’S finder said he is super friendly and noticed him 2 days ago with swollen RF paw and not placing any weight on it. BILL has RFL presented swollen and edematous with active bleeding and pus coming from several puncture sites. Bill will need more intensive care. Please help Bill today.
Brooklyn Center
Bill 21008
Care Center Location: Brooklyn
ZIP Code From: 11368
Intake Type: Stray (DOH victim hold)
Medical Behavior: Green
Age: 10 years
Sex: Male
Weight: 9 lbs
DVM Intake Exam
Estimated age: approx 10 yo
Microchip noted on Intake? neg
Microchip Number (If Applicable):
History : Stray. Finder said he noticed p 2 days ago with swollen RF paw and not placing any weight on it. Finder may want to adopt p, said p has been very friendly.
Subjective: Q-BAR. Friendly and well behaved during initial exam. Sneezed once during exam, possible URI. Painful on RFL and did allow examination. Gave telazol.
Observed Behavior –
Evidence of Cruelty seen – n
Evidence of Trauma seen – n
Objective
T =
P = wnl
R = eup
BCS 5/9
MM pink, slightly tacky, mild delay skin turgor
EENT: Eyes clear, AU black waxy debris, no ocular discharge noted, very mild serous nasal discharge
Oral Exam: neg oral, no ulcers/lesions, missing several teeth, fractured canines
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated, moderately sized bladder, soft, nonpainful
U/G: MI, 2 testicles
MSI: Ambulatory x 3. NWB RFL. RFL presented swollen and edematous with active bleeding and pus coming from several puncture sites. RFL was clipped/cleaned and revealed several bite wounds with pocketing (at least 8) from the carpus extending up along the atebrachium. The skin was very fragile, sloughing while being clipped, and bled easily. Possible fracture of metacarpal #2 seen on rads. No ectoparasites seen. No masses noted, healthy hair coat
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal: normal externally
Assessment:
RFL bite wounds with pocketing
possible fracture right metacarpal #2
possible URI
dehydration
intact
Prognosis: fair
Plan:
– ctm in medical
– Sedated with telazol, followed by gas anesthesia
– LRS 100 mL SQ today and tomorrow. Extend PRN.
– Clipped and cleaned RFL, probed bite wounds, and flushed wounds with sterile LRS.
– Rads 2 view RFL — possible fx of metacarpal #2
– Simbadol 0.56 mL SQ SID x 5 days. Extend PRN
– Onsior 8.4mg SQ once today. Then 6mg PO SID x 3 days.
– Clavamox (62.5mg/ml) 1 mL PO BID x 14 days.
– Monitor for any developing URI
– E-collar always
– Recommend transfer so p can receive more intensive care and monitoring, IVF, IV antibiotics, surgical consult, and daily bandage changes +/- drain placement
SURGERY:
Permanent waiver due to old age
MEDICAL:
25-Feb-2018
Progress Exam
Vet Notes: 1:08 PM
[Progress Exam Template]
S: P doing well
O:
EENT: Clear OU
Oral Exam:
H/L: No ma
Abd:
MSI: Wounds on RF leg are scabbed over, no discharge, appear to be healing
Mentation:
A: RF leg wounds
P: ctm
Is the Initial Medical Status being Changed?
New Medical Status:
Is the Initial Behavior Status being Changed?
New Behavior Color:
VET-P 991372
24-Feb-2018
Progress Exam
Vet Notes: 8:51 AM
Recheck wounds RFL
S/O: BARH. Eating well. Normal urine. Normal and soft stool.
EENT: Nuclear sclerosis, no ocular discharge, mild mucoid nasal discharge
HL: Normal RR/RE, sounds congested
INTEG: Full coat, healing wounds at RFL – all healing well, minimal swelling, no signs of infection
MS: Ambulatory x 4
UG: Male
A: Geriatric, wounds, possible URI
P: Continue with current treatment and monitoring plan. Good prognosis
VET 990844
22-Feb-2018
Progress Exam
Vet Notes: 11:19 AM
Progress exam
History : Stray intake 2/18 with bite wounds to RFL. Started on clavamox, simbadol, onsior, SQ LRS
Rads 2 view RFL — possible fx of metacarpal #2
2/19-started baytril, metronidazole
2/20-wound treatment
Subjective: QAR to dull, hydrated. Eating well. Intermittent WB on RFL. Normal bm and u. Once out of the cage perks up a little but is shut down in the cage. His RFL has significantly improved.
Objective
P = wnl
R = wnl
BCS 5/9
EENT: Eyes clear, mild debris AU, no ocular discharge noted, serous nasal discharge and congestion
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic but congested
ABD: Non painful, no masses palpated
U/G: MI, 2 testicles descended
MSI: Ambulatory x 3 with intermittent weight bearing on RFL. RFL antebrachium to distal carpi has several healing wounds with a healthy granulation tissue and no d/c. Swelling has almost resolved. No ectoparasites seen. No masses noted, healthy hair coat
CNS: Mentation appropriate – no signs of neurologic abnormalities
Assessment:
RFL bite wounds-improved
Fracture right distal phalanx #2
URI
Dental disease
Prognosis: fair
Plan:
CTM while at BACC
Continue clavamox until 3/3
Last day of simbadol
Continue baytril 5mg/kg PO SID until 3/1
Continue metronidazole 15mg/kg PO BID until 3/1
E-collar always
Recommend transfer to hospital can receive more intensive care and monitoring, IVF
DOH-V hold
20-Feb-2018
Progress Exam
Vet Notes: 10:25 AM
Recheck abscess RFL
S/O: BAR. Very mild dehydration. Allows all handling. BCS 5/9
EENT: Nuclear sclerosis, no ocular discharge, very mild mucopurulent nasal discharge, ears WNL; pink mm, dental disease
HL: Normal thoracic auscultation, mild upper respiratory congestion
ABD: Soft, non tender
MSI: Ambulatory x 4, Full coat, multiple wounds to distal right antebrachium, several puncture wounds covered with dark scabs, mild serosanguinous discharge draining, ~1cm full thickness wound at lateral carpus, moderate scabbing
UG: Male
A: Geriatric, healing wounds/abscess RFL, dental disease
P: Continue with current treatment and monitoring plan. Wounds cleaned with nolvasan. No surgical repair indicated at this time. Consider wet-dry bandage to aid in healing with placement. Good prognosis
VET 990844
20-Feb-2018
19-Feb-2018
Progress Exam
Vet Notes: 2:50 PM
Progress exam
History : Stray intake 2/18 with bite wounds to RFL. Started on clavamox, simbadol, onsior, SQ LRS
Rads 2 view RFL — possible fx of metacarpal #2
Subjective: QAR, ~5-6% dehydrated. Eating well. Intermittent WB on RFL. Purulent and blood discharge will extruding from wound. URI signs persistent.
Objective
P = wnl
R = wnl
BCS 5/9
EENT: Eyes clear, mild debris AU, no ocular discharge noted, serous nasal discharge and congestion
Oral Exam: adult dentition with severe dental disease and fractured dentition
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupneic but congested
ABD: Non painful, no masses palpated
U/G: MI, 2 testicles descended
MSI: Ambulatory x 3 with intermittent weight bearing on RFL. RFL antebrachium to distal carpi has several bite wounds with purulent and bloody discharge and moderate swelling. Skin appears necrotic. No ectoparasites seen. No masses noted, healthy hair coat
CNS: Mentation appropriate – no signs of neurologic abnormalities
Assessment:
RFL bite wounds with pocketing
Fracture right distal phalanx #2
URI
Dental disease
Prognosis: fair
Plan:
CTM while at BACC
Continue clavamox until 3/3
Continue onsior until until 2/21
Continue SQ LRS until 2/21
Continue simbadol until 2/22
Start baytril 5mg/kg PO SID x10d until 3/1
Start metronidazole 15mg/kg PO BID x10d until 3/1
E-collar always
Recommend transfer to hospital can receive more intensive care and monitoring, IVF, IV antibiotics, surgical consult, and daily bandage changes +/- drain placement
Will have wound treatment in house tomorrow
VET 991416
18-Feb-2018
DVM Intake
Vet Notes: 2:33 PM
[DVM Intake]
DVM Intake Exam
Estimated age: approx 10 yo
Microchip noted on Intake? neg
Microchip Number (If Applicable):
History : Stray. Finder said he noticed p 2 days ago with swollen RF paw and not placing any weight on it. Finder may want to adopt p, said p has been very friendly.
Subjective: Q-BAR. Friendly and well behaved during initial exam. Sneezed once during exam, possible URI. Painful on RFL and did allow examination. Gave telazol.
Observed Behavior –
Evidence of Cruelty seen – n
Evidence of Trauma seen – n
Objective
T =
P = wnl
R = eup
BCS 5/9
MM pink, slightly tacky, mild delay skin turgor
EENT: Eyes clear, AU black waxy debris, no ocular discharge noted, very mild serous nasal discharge
Oral Exam: neg oral, no ulcers/lesions, missing several teeth, fractured canines
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated, moderately sized bladder, soft, nonpainful
U/G: MI, 2 testicles
MSI: Ambulatory x 3. NWB RFL. RFL presented swollen and edematous with active bleeding and pus coming from several puncture sites. RFL was clipped/cleaned and revealed several bite wounds with pocketing (at least 8) from the carpus extending up along the atebrachium. The skin was very fragile, sloughing while being clipped, and bled easily. Possible fracture of metacarpal #2 seen on rads. No ectoparasites seen. No masses noted, healthy hair coat
CNS: Mentation appropriate – no signs of neurologic abnormalities
Rectal: normal externally
Assessment:
RFL bite wounds with pocketing
possible fracture right metacarpal #2
possible URI
dehydration
intact
Prognosis: fair
Plan:
– ctm in medical
– Sedated with telazol, followed by gas anesthesia
– LRS 100 mL SQ today and tomorrow. Extend PRN.
– Clipped and cleaned RFL, probed bite wounds, and flushed wounds with sterile LRS.
– Rads 2 view RFL — possible fx of metacarpal #2
– Simbadol 0.56 mL SQ SID x 5 days. Extend PRN
– Onsior 8.4mg SQ once today. Then 6mg PO SID x 3 days.
– Clavamox (62.5mg/ml) 1 mL PO BID x 14 days.
– Monitor for any developing URI
– E-collar always
– Recommend transfer so p can receive more intensive care and monitoring, IVF, IV antibiotics, surgical consult, and daily bandage changes +/- drain placement
– Need to update New Hope, they were not available today.
SURGERY:
Permanent waiver due to old age
VET-P 991459
18-Feb-2018
Spay-Neuter Waiver Documentation
Vet Notes: 1:36 PM
[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.
For more information on adopting from the NYC AC&C, or to find a rescue to assist, please read the following: http://urgentpodr.org/adoption-info-and-list-of-rescues. If you are local to the Tri-State, New England, and the general Northeast United States area, and you are SERIOUS about adopting or fostering one of the animals at NYC ACC, please read our MUST READ section for instructions, or email [email protected]. Our experienced volunteers will do their best to guide you through the process. * We highly discourage everyone from trusting strangers that send them Facebook messages, offering help, for it has ended in truly tragic events.* For more info on behavior codes and ratings, please click here: http://information.urgentpodr.org/acc-placement-status-descriptions. For answers to Frequently Asked Questions, please see: http://information.urgentpodr.org/category/frequently-asked-questions/. You can call (212) 788-4000 for automated instructions.
View all entries in: Safe Cats 2018-03