JOLENE – A1080166
Gone - 7-8-2016 Manhattan
**MUST BE PULLED BY A NEW HOPE RESCUE**
JOLENE – A1080166
FEMALE, BLACK / WHITE, DOMESTIC SH MIX,6 weeks
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition EXAM REQ Intake Date 07/06/2016, From NY 10468, DueOut Date 07/09/2016,
Medical Behavior Evaluation BLUE
Medical Summary Sex: Female Scan: Negative Estimated age: 6 weeks based on weight Fleas: No flea dirt S: Meows and hisses when tail base and pelvis are manipulated. Otherwise, friendly and allows exam. O: BAR-H, BCS 4.5/9, MMs pink and moist EENT: No discharge OU, AU, nose. Clean deciduous teeth – canines appear to be worn down. PLNs: Not enlarged. H/L: Tachycardic, NSR, NMA. Eupnic, quiet lung sounds. Abd: Soft, no pain on palpation, no masses palpated M/S/I: Swelling and increased laxity at tail base – pt resists close exam of this area (struggles, mews and hisses). Can step with hind legs but prefers to sit down and not walk. Bloody discharge on medial aspect of left hind leg – no wounds noted. Rectal: Anus slightly bulging, bloody discharge on anus. UG: Female, bloody discharge on vulva. A: Trauma, likely fracture at tail base +/- pelvis, possible internal injuries (GI rupture?) given bloody discharge from anus or vulva Short-term prognosis: Fair Current surgery status: Temporary waiver for trauma and likely fracture. P: 1. Transfer to MACC (emergency transport if available) 2. Schedule sedated rads and closer exam of anorectal region for tomorrow morning 3. Buprenorphine 0.04 ml SQ BID x7 days 4. Amoxiclav 0.21 ml PO BID x5 days, extend if source of bloody discharge is found that warrants it 5. Metronidazole 0.15 ml PO BID x5 days, extend if source of bloody discharge is found that warrants it 6. Gave 0.37 ml ponazuril and 0.37 ml Panacur during exam 1088
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