JUNIPER – A1113760
Safe - 6-2-2017 Brooklyn
SAFE 6/2/17 Poor Juniper is a 3 yr old male that has a severe wound on his left pelvic limb/ paw. He will need immediate medical attention.
JUNIPER – A1113760
MALE, BRN TABBY, DOMESTIC SH,3 yrs
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition INJ SEVERE Intake Date 05/31/2017, From NY 11379, DueOut Date 06/03/2017,
Medical Behavior Evaluation YELLOW
Medical Summary DVM Intake Exam Estimated age: 3 Microchip noted on Intake? none History : Injured – LRL caught in bear claw trap. Subjective: QAR. 5% dehydrated. Observed Behavior – Will try to flee, not hissing or biting. Evidence of Cruelty seen – none Evidence of Trauma seen – YES Objective T = P = 200 R = BCS=4/9 EENT: Eyes clear, ears clean, no nasal discharge noted Oral Exam: Painful when pressing caudal teeth R side. Some gingivitis and resorptive lesions noted. PLN: No enlargements noted H/L: NSR, NMA, MM pk, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: male intact – 2 testicles MSI: Ambulatory x 3 – major trauma to LRL – paw markedly swollen and bloody with open wound, moderate swelling from stifle down to hock but no brusing noted, no laxity or crepitus palpates. Skin free of parasites, no masses noted, healthy hair coat besides wound LRL. CNS: mentation appropriate – no signs of neurologic abnormalities Rectal: Assessment: Severe wound L pelvic limb/ paw – no fx noted. Plan: Simbadol 0.55 cc SQ, then waited 15 min for exam. Repeat daily. Telazol 0.1 cc IM at 13:55. Clip and clean wounds. Bandage. X-ray – lateral and AP of pelvic limbs – some emphysema seen mid metatarsals but no fx seen. SQF 150 cc. Pen G 0.5 cc SQ. Clavamox 1 cc po bid x 10. Prognosis: Guarded for paw – will need to monitor healing, may need amputation but likely not. SURGERY: Temporary waiver due to injury.
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