DELI – A1113311
Safe - 5-31-2017 Brooklyn Rescue: Staten Island Hope Please honor your pledges: http://www.statenislandhopeanimalrescue.org/
SAFE 5/31/17 Per our vet, our very sweet DELI is doing better today, is up and walking, much more alert and meowing! She will still require quite a lot of hospital care and expect at least one surgical procedure will be needed in the near future, but her outlook is has much improved! PLEASE HELP HER TODAY!
DELI was brought in with a skin laceration that was covered in maggots – needs rescue and follow up medical.
BROOKLYN CENTER
DELI – A1113311
FEMALE, BLACK / WHITE, DOMESTIC SH,2 yrs
STRAY – STRAYAVAI, NO HOLD Reason STRAY
Intake condition INJ MINOR Intake Date 05/27/2017, From NY 11208, DueOut Date 05/30/2017,
Medical Behavior Evaluation GREEN
Medical Summary DVM Intake Exam Estimated age:2 yo Microchip noted on Intake: Negative History: Stray, has a collar with a bell Subjective: Observed Behavior – QAR friendly Evidence of Cruelty seen – None Evidence of Trauma seen – Yes Objective: Dehydrated 7%; T = 100 P = 160 R = 28 BCS 4/9 EENT: Eyes clear, ears clean, no nasal discharge noted Oral Exam: No dental tartar, allpermanent teeth are present, MM Pink and moist, PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: Intact female MSI: Ambulatory x 3, skin laceration cover maggots, large laceration about 15 cm long, (ONLY SKIN) no masses noted, dirty hair coat CNS: Mentation appropriate – no signs of neurologic abnormalities (full neurologic exam not performed) Rectal: Not performed Assessment 1. Wound and maggot infestation 2. Large laceration on the right leg 3. Underweight Plan/Treatment/Recommendations – Mild sedation with Tilazol – Clip and clean wound – Give a dose of Convenia – Wt:5.74 lb – FIV/FeLV snap test (negative) – Vaccines (FVRCP SQ RFL; Rabies SQ RHL) – Dewormed (Pyrantel) – Flea prevention treatment – Microchip place (Between shoulder blades):981020019657213 – IVC IVF 1 L LRS + 20 mEq KCL at 30 ml /hr for 2 hours then 15 ml /hr – Amoxiclav 1 ml PO BID14days – Simbadol 0.33 ml SQ SID 3 days Prognosis:Good if treated SURGERY: Temporary waiver due to severe skin laceration and wound infested with Maggots
Weight 5.7
MEDICAL
5/30:
05/29/17
Recheck cat with laceration, wounds and previous maggot infestation.
S/O: QAR. Resting, when roused, lifted head and meowed, stood up on her own. Not eating or drinking. mm=lt pink, moist, CRT<2 s. HR=200, RR=24.
EENT: No oculonasal discharge.
H/L: Lungs clear, no murmurs/arrhythmias.
MS/INTEG: Amb x 4 with severe lameness right hind, mild lameness left hind. Drain present medial L hind leg with purulent discharge. Sutured laceration medial left hind leg, several areas appear to be dehiscing and skin is very thin. Mod. non-pitting edema as well as SQ emphysema distal right hind leg from stifle to foot. Skin in this area is becoming thin, almost translucent medially, is very sensitive when touched. Erythema, bruising ventral abdomen with firm SQ swelling. There are now two open areas in right inguinal/caudal abdominal area. Large amount of moisture and dried debris medial hind limbs and ventral abdomen. No maggots found.
A: Young adult cat with left hind limb injury/laceration, edema and SQ emphysema, and skin in contralateral hind leg and inguinal region, SQ swelling over ventral abdomen with new wounds developing. Possible abdominal wall trauma with hernia.
Hypothermia has resolved, able to maintain body temp.
Dihiscence of laceration repair due to devitalized tissues, infection, moisture.
Overall condition is stable to improved.
P: Cleaned away debris over hind limbs with dilute chlorhexidene solution. Flushed all wounds and drain with dilute chlorhexidene.
Continue Baytril 22.7 mg/ml 0.6 ml IV q 24 hours, Clavamox orally, Simbadol, and wound treatment.
Increased IV LRS + 20 mEq/L to 25 ml/hr due to large amount of fluid loss in wound exudate.
Fair prognosis. Expect more skin necrosis to develop, evetually cat will need additionally surgery to debride and explore affected areas.
5/29:
05/29/17
Recheck cat with laceration and maggot infestation.
S/O: Lethargic, resting in lateral recumbency. More reponsive than yesterday and lifts her head up, will sit up in sternal recumbency and hold up her head. Not eating or drinking. mm=lt pink, moist, CRT<2 s. HR=200, RR=24.
EENT: No oculonasal discharge.
H/L: Lungs clear, no murmurs/arrhythmias.
MS/INTEG: Non-ambulatory, very weak when held up to stand. Drain present medial L hind leg with purulent discharge. Sutured laceration medial left hind leg, several areas appear to be dehiscing and skin is very thin. Mod. non-pitting edema as well as SQ emphysema distal right hind leg from stifle to foot. Skin in this area is becoming thin, almost translucent medially, is very sensitive when touched. Erythema, bruising ventral abdomen with firm SQ swelling and a 5 mm open wound developing. Large amount of moisture and dried debris medial hind limbs. Two adult maggots found (and removed).
A: Young adult cat with left hind limb injury/laceration, edema and SQ emphysema developing in contralateral hind leg, SQ swelling over ventral abdomen with new wound developing, maggot infestation. Possible abdominal wall trauma with hernia.
Hypothermia has resoved.
Dihiscence of laceration repair due to devitalized tissues, infection, moisture.
Suspect severe infectious process secondary to soft tissue trauma to abdomen and hind limbs, possible lymphatic compromise, with skin necrosis developing. SQ emphysema R hind likely be due to penetrating trauma.
P: Cleaned away debris over hind limbs with dilute chlorhexidene solution. Flushed all wounds and drain with dilute chlorhexidene.
Continue Baytril 22.7 mg/ml 0.6 ml IV q 24 hours, Clavamox orally, Simbadol, and wound treatment.
Increased IV LRS + 20 mEq/L to 25 ml/hr due to large amount of fluid loss in wound exudate.
Poor prognosis.
5/28:
05/28/17
Recheck cat with laceration and maggot infestation.
S/O: Lethargic, resting in lateral recumbency. Responsive when touched, no attempts to get up. Not eating or drinking. mm=lt pink, moist, CRT<2 s. HR=200, RR=24.
EENT: Mild 3rd eyelid protrusion OU. No oculonasal discharge.
H/L: Lungs clear, no murmurs/arrhythmias.
MS/INTEG: Non-ambulatory, very weak when held up to stand. Drain present medial L hind leg with purulent discharge. Sutured laceration medial left hind leg, several areas appear to be dehiscing. Mod. non-pitting edema distal right hind leg from stifle to foot. Erythema, bruising ventral abdomen with painful, firm SQ swelling. Several adult maggots on medial thighs.
A: Young adult cat with left hind limb injury/laceration, edema developing in contralateral hind leg, SQ sweling over ventral abdomen, maggot infestation, hypothermia. DDx – severe infectious process, severe soft tissue trauma with lymphatic compromise, abdominal wall injury, sepsis.
P: Lat/VD pelvic and hind limb rads: No fractures visible.
Gave Capstar 2-25 lb 1 tab PO.
Start Baytril 22.7 mg/ml 0.6 ml IV q 24 hours x 7 days.
Continue Clavamox, Simbadol, wound treatment, heat support, IV fluids.
Poor prognosis.
:
5/27:
Laceration repair
Clip and clean wound
Remove all moggots
Laceration repair (debried all wound) and apply a pen rose drain in the wound, close all lacaratioin with indivudual skin stiches a long all skin wound
Recommend to fush wound twice a day for 3-4 days
DVM Intake Exam
Estimated age:2 yo
Microchip noted on Intake: Negative
History: Stray, has a collar with a bell
Subjective:
Observed Behavior – QAR friendly
Evidence of Cruelty seen – None
Evidence of Trauma seen – Yes
Objective:
Dehydrated 7%; T = 100 P = 160 R = 28 BCS 4/9
EENT: Eyes clear, ears clean, no nasal discharge noted
Oral Exam: No dental tartar, allpermanent teeth are present, MM Pink and moist,
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G: Intact female
MSI: Ambulatory x 3, skin laceration cover maggots, large laceration about 15 cm long, (ONLY SKIN) no masses noted, dirty hair coat
CNS: Mentation appropriate – no signs of neurologic abnormalities (full neurologic exam not performed)
Rectal: Not performed
Assessment
1. Wound and maggot infestation
2. Large laceration on the right leg
3. Underweight
Plan/Treatment/Recommendations
– Mild sedation with Tilazol
– Clip and clean wound
– Give a dose of Convenia
– Wt:5.74 lb
– FIV/FeLV snap test (negative)
– Vaccines (FVRCP SQ RFL; Rabies SQ RHL)
– Dewormed (Pyrantel)
– Flea prevention treatment
– Microchip place (Between shoulder blades):981020019657213
– IVC IVF 1 L LRS + 20 mEq KCL at 30 ml /hr for 2 hours then 15 ml /hr
– Amoxiclav 1 ml PO BID14days
– Simbadol 0.33 ml SQ SID 3 days
Prognosis:Good if treated
SURGERY:
Temporary waiver due to severe skin laceration and wound infested with Maggots
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