BRETT – A1113867
Gone - 6-1-2017 Brooklyn
DIED 6/1/17 BRETT has some trauma and has trouble using hind legs – has hind limb paralysis, possible tibial fracture on left hind leg – has an open wound at tail base, possible pelvic fracture or spinal injury which needs further medical eval. Needs xrays and vet care asap!! Allows all handling!
BRETT – A1113867
MALE, BLACK, DOMESTIC SH,1 yr
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition INJ SEVERE Intake Date 06/01/2017, From NY 11435, DueOut Date 06/04/2017,
Medical Behavior Evaluation BLUE
Medical Summary 06/01/17 DVM Intake Exam Estimated age: 1 yrs Microchip noted on Intake? No. History : Stray cat, noted to have trouble using hind legs. Subjective: Observed Behavior – Quiet, alert, difficult to fully determine behavior due to injuries but allows all handling. No attempts to flee. Evidence of Cruelty seen – No. Evidence of Trauma seen – Yes. Objective: QAR. mm=lt pink, tacky, CRT=2 s. HR=160, RR=20. BCS=2/9. ORAL: All adult teeth present, excellent dental condition, no oral lesions. EENT: Eyes sunken OU. Eyes clear, ears clean, no nasal discharge noted. PLN: No enlargements noted. H/L: Lungs clear, no murmurs/arrhythmias. ABD: Non painful, no masses/organomegaly palpated. U/G: Male, intact, both testicles palpable. Urinary bladder small, soft. MS/NEURO: Non-weight bearing both hind limbs. Swelling left hind leg distal to stifle, palpable thickening at left stifle/proximal tibia. Pos. withdrawal both hind legs, equivocal nociception. INTEG: Open, contaminated wound at base of tail dorsally and left side, mod purulent fluid but no maggots seen. Dry, scruffy, dirty haircoat. Decreased skin turgor. A: Approx. 1 yr old cat with dehydration, hind limb paralysis, possible tibial fracture LH, open wound at tail base. R/o spinal injury, pelvic fracture. P: Simbadol 1.8 mg/ml 0.3 ml SQ. Continue q 24 hours x 3 days. Convenia 80 mg/ml 0.3 ml SQ. 200 ml LRS SQ. Continue 100 ml q 24 hours x 3 days. Cleaned wound with dilute chlorhexidene, applied SSD cream. Continue wound treatment BID x 3-5 days. House in medical. Temporary waiver from neuter surgery due to injuries. Schedule for radiographs of hind limbs and pelvis. Guarded prognosis.
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