JACK – A1115991
Gone - 6-22-2017 Brooklyn
DIED 6/22/17 Jack was found in a driveway unable to move for 2 days – he is unable to walk – has some pain and injury to right hind limb – needs further medical evaluation to determine what is wrong. He is 4 yrs old and allows all handling.
JACK – A1115991
MALE, BRN TABBY / WHITE, DOMESTIC SH,4 yrs
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition ILLNESS Intake Date 06/20/2017, From NY 11369, DueOut Date 06/23/2017,
Medical Behavior Evaluation BLUE
Medical Summary DVM Intake Exam Estimated age:4 years Microchip noted on Intake? n History : stray cat found a driveway and unable to nove for 2 days Subjective: patient having trouble ambulating from hind limbs. Otherwise QAR, ~7% Dehydrated Observed Behavior – allowed all handling with out any issues Evidence of Cruelty seen – n Evidence of Trauma seen – mild swelling to R hind proximal limb Objective P = 176 R = 36 BCS 4/9 EENT: Eyes clear, ears clean, no nasal discharge noted Oral Exam: wnl PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: both testicles palpable MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat CNS: mentation appropriate – signs of neurologic abnormalities – decreased CP def to R hind limb, decreased, deep pain to R hind limb. Patient unable to ambulate, however, no ataxia. Assessment – R/O trauma vs toxicity vs other. Plan – L lateral and VD Pelvis radiographs. No fractures or luxations noted. mild sub-q emphasemia to R hind proximal limb on lateral surface. CBC/CHEM Simbadol 0.39ml SQ SID 3 days Prognosis: Fair. SURGERY: Temporary waiver due to medical causes
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