JOHN – A1112503
Gone - 5-19-2017 Brooklyn
DIED 5/19/17 Cat was possibly hit by a car – he has bruising to lungs from chest trauma – very weak – needs further medical.
JOHN – A1112503
MALE, WHITE / GRAY, DOMESTIC SH MIX,4 yrs
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition INJ SEVERE Intake Date 05/19/2017, From NY 11206, DueOut Date 05/22/2017,
Medical Behavior Evaluation ORANGE
Medical Summary DVM Intake Exam Estimated age: 1-2yrs Microchip noted on Intake? no History : Subjective: Cat is QAR Observed Behavior – cat is crouched sternally in carrier, labored/open mouth breathing and hissing, ears flat, field driver reports cat was very difficult to catch, tries to flee whenever touched. Evidence of Cruelty seen – no Evidence of Trauma seen – yes Objective T = 95.6 F P = 110 (after sedation) R = 72 (before sedation), 40 (after sedation) BCS 4/9 (2.5/5) EENT: Eyes clear, ears clean, no nasal discharge noted Oral Exam: Ptyalism; healthy adult dentition; appears to have small amount of blood on lower canine (from biting tongue); Grade 0-1/4 dental dz PLN: No enlargements noted H/L: Grade II/VI murmur, CRT < 2, Decreased lung sounds, bilaterally (especially caudo-dorsal lung fields). ABD: nsf U/G: wnl; both testicles palpable MSI: Cat is able to stand when aroused, but very weak and sinks back down into sternal recumbency. Coat is very dirty and paw pads are black; there is an approx 2cm area of alopecia on the medial aspect of the right thigh. Increased skin tent. CNS: mentation appropriate – no signs of neurologic abnormalities Rectal: not performed Assessment: Suspect cat was HBC, no obvious external wounds or injuries, no obvious swelling or laxity consistent with fractures. Plan: Took radiographs. Right lateral VD chest reveals increased broncho-interstitial pattern consistent with pulmonary contusions (bruising to lungs from chest trauma such as being HBC). Right lateral and VD abdomen reveals loss of serosal detail (possible free fluid in abdomen) Prognosis: Fair-Poor SURGERY: Temporary waiver due to trauma
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