GLENN – A1115414
Safe - 6-17-2017 Manhattan Rescue: K9KASTLE Please honor your pledges: https://www.classy.org/checkout/donation?eid=127094
SAFE 6/17/17 Glenn is a good cat that possibly has CH and a fractured jaw @MACC. Meet Glenn: Glenn is a good cat that just needs some extra love. She possibly has a fractured jaw and possibly has CH. She will need extra medical care but with the right amount TLC she can still live a great life. Let’s help find this cat the care she deserves!
MANHATTAN CENTER
GLENN – A1115414
FEMALE, WHITE / BRN TABBY, DOMESTIC SH,1 yr
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition INJ MINOR Intake Date 06/14/2017, From NY 10472, DueOut Date 06/17/2017,
Medical Behavior Evaluation BLUE
Medical Summary 06/15/17 09:56 DVM Intake Exam Estimated age: 1yr old Microchip noted on Intake? no History : stray, admitted with epistaxis and hindlimb lameness Subjective: Observed Behavior – sweet, allowed exam easily, did not eat overnight but ate some canned diet in am, urinated in box Evidence of Cruelty seen – no Evidence of Trauma seen – yes Objective T = not obtained P = >200 R = 30 BCS 4/9 EENT: Eyes clear, ears clean, no nasal discharge noted Oral Exam: no dental tartar, bruising on mucosa over mandible, mandibular symphysis fracture, minor assymmetry in mandible with possible L TMJ fx, hard palate WNL PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, eupnic, increased lung sounds ABD: Non painful, no masses palpated U/G: female, minimal vuvlar & mamm development MSI: flea dirt, no live fleas, mandibular symphysis laxity, 4xambulatory, intermittently falls to either side in hind while walking, mild crepitus in carpus of RFL CNS: mentation appropriate, withdrawal WNL x4 limbs, forelimb CPs & wheelbarrowing WNL, hindlimbs CPs prolonged, ataxic with widebase stance in hind Rectal: Assessment mandibular symphysis fracture L TMJ luxation (minor) hindlimb ataxia r/o pelvic fx vs spinal vs other RFL carpal fx vs ST injury vs other Plan 0.05ml Dexdorm & 0.05ml Butorphanol IM Thoracic Rads Pelvic Rads carpal Rads 0.13ml Hydromorphone SQ BID x3d, switch to Buprenex or Simbadol when in stock 0.26ml Onsior SID x 3d Prognosis: good SURGERY: Temporary waiver due to fracture
Weight 5.7
Medical:
Re-exam (6/16/17)
S/O: eating, urine in litterbox
M/S: amb x4, mild wobbliness in HLs with wide stance at times, but amb x4, BCS 4/9. No palpable facial/jaw fractures, mandibular symphyseal separation noted yesterday- not appreciated today
H/L: NSF
EENT: mild blood on ventral gums, no pain, mild gingivitis, palpable thyroid nodule bilaterally, no URI signs, no hard palate fx, scant dried debris ventral to nares
ABN: SNP, feces in colon
UROGEN: FI, grossly normal, no palpable MGTs
NEURO: dilated pupils (on hydromorphone), no spinal pain, no CP deficits- just a little prolonged to replaced HL paws, otherwise neurologically appropriate
A: ataxia in HL: r/o cerebellar hypoplasia, other
mandibular symphyseal separation noted yesterday: r/o mild
palpable thyroid nodule
mild periodontal dz
P: switch to simbadol 1.8mg/ml: 0.35ml SQ SID x3 and con’t with onsior in case of pain
alerted NH as to p
long term rec cbc/chem/t4 as general health screen
prognosis: good- cats with cerebellar hypoplasia can have a great quality of life- just need to be mindful of avoiding necessity to have to jump long/high distances, make sure food/water/litterbox easy to reach.
Symphyseal separation should heal with time- eating well now- while this can be referred to as a “fracture” it’s actually a separation/break in the soft tissues that connect teh two sides of the mandible. This seems to be very mild, could heal with tinture of time. To further assess- could perform dental rads to determine the exact extend.
DVM Exam (6/15/17)
Estimated age: 1yr old
Microchip noted on Intake? no
History : stray, admitted with epistaxis and hindlimb lameness
Subjective:
Observed Behavior – sweet, allowed exam easily, did not eat overnight but ate some canned diet in am, urinated in box
Evidence of Cruelty seen – no
Evidence of Trauma seen – yes
Objective
T = not obtained P = >200 R = 30 BCS 4/9
EENT: Eyes clear, ears clean, no nasal discharge noted
Oral Exam: no dental tartar, bruising on mucosa over mandible, mandibular symphysis fracture, hard palate WNL
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, eupnic, increased lung sounds
ABD: Non painful, no masses palpated
U/G: female, minimal vuvlar & mamm development, no spay scar or tatoo
MSI: flea dirt, no live fleas, mandibular symphysis laxity, 4xambulatory, intermittently falls to either side in hind while walking, mild crepitus in carpus of RFL
CNS: mentation appropriate, withdrawal WNL x4 limbs, forelimb CPs & wheelbarrowing WNL, hindlimbs CPs prolonged, ataxic with widebase stance in hind
Rectal:
Assessment
mandibular symphysis fracture
hindlimb ataxia r/o pelvic fx vs spinal vs other
RFL carpal fx vs ST injury vs other
Plan
0.05ml Dexdorm & 0.05ml Butorphanol IM
Thoracic Rads: unremarkable
Pelvic Rads: no fx or lux, vertebra appear well aligned
caprpal rads onely lat of R caprus no obvious fx or ST swelling noted
0.13ml Hydromorphone SQ BID x3d, switch to Buprenex or Simbadol when in stock
0.26ml Onsior SID x 3d
Prognosis: good
SURGERY:
Temporary waiver due to fracture
LVT Intake Exam (6/15/17)
Sex: intact female
Age: appx 1y+
Mentation: BARH
Eyes: clear
Ears: clean
Nose: no d/c
Teeth: minimal staining
If abnormal BCS: underweight 4/9
Skin: WNL
Hair Coat: dirty haircoat as if outdoors, some car grease debris
Declawed: no
Any injuries: hinds seems weak, poor balance and crouched, swollen chin (soft tissue only, fluid palpated), epistaxis and slightly abraded lips (high rise vs other trauma)
Behavior: allowed all handling, quiet
Medication: N/A, preventatives given
Behavior:
Medical Green (allows all handling)
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