KAL – A1114282
Safe - 6-17-2017 Brooklyn
SAFE 6/17/17 Kal needs follow up medical care for the wound on his neck and his fractured tooth.
KAL HAS A LARGE OPEN WOUND WHICH IS DRAINING. IS FRIENDLY, AND NEEDS FOLLOW UP MEDICAL!
BROOKLYN CENTER
KAL – A1114282
NEUTERED MALE, GRAY TABBY / WHITE, DOMESTIC SH MIX,2 yrs
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition ILLNESS Intake Date 06/05/2017, From NY 11377, DueOut Date 06/08/2017,
Medical Behavior Evaluation BLUE
Medical Summary DVM Intake Exam Estimated age:2 yo Microchip noted on Intake? n History : stray Subjective: large open wound/draining tract ventral to AD Observed Behavior – allows all exam Evidence of Cruelty seen – n Evidence of Trauma seen – yes Objective P = 120 R = wnl BCS 5/9 EENT: Eyes clear, ears clean, no nasal discharge noted. Oral Exam: upper left canint chipped PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: 2 testes MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat CNS: mentation appropriate – no signs of neurologic abnormalities Assessment: wound/draining tract Plan: sedate, neuter and wound/explore wound +/- close Prognosis: good SURGERY: Okay for surgery
Weight 10.1
06/06/17
Lying towards back of kennel, facing forward with a low body. He tolerates petting while avoiding eye contact and licking his lips. Needs more time to adjust. Sprayed feliway.
06/07/17
Lying in back of kennel with a low body, head down. Tolerates petting while breathing rapidly and turning head to watch my hand. May be uncomfortable due to medical condition. Sprayed feliway.
Medical::
06/05/17:
DVM Intake Exam
Estimated age:2 yo
Microchip noted on Intake? n
History : stray
Subjective: large open wound/draining tract ventral to AD
Observed Behavior – allows all exam
Evidence of Cruelty seen – n
Evidence of Trauma seen – yes
Objective
P = 120 R = wnl BCS 5/9
EENT: Eyes clear, ears clean, no nasal discharge noted.
Oral Exam: upper left canint chipped
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G: 2 testes
MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat
CNS: mentation appropriate – no signs of neurologic abnormalities
Assessment: wound/draining tract
Plan: sedate, neuter and wound/explore wound +/- close
Prognosis: good
SURGERY: Okay for surgery
PE: Wound on neck
Exam & surgery performed
Feline neuter
Anesthesia – 0.1mL Telazol induction.
Sx. – Routine scrotal castration. No sutures placed, incisions left open to drain. Green linear tattoo placed on ventral abdomen.
0.45 mL ONSIOR SQ injectable and 0.61 mL SYMBADOL IM for pain management.
WOUND TREATMENT
LEFT LATERAL RECUMBENY 3 CM WOUND THROUGH RIGHT CHEEK PAD, VENTRAL TO EAR PINNA
HEALTHY GRANULATION BED, BLEEDS READLY WHEN DEBRIDED. DEPTH OF WOUND 1 CM, WITH TWO DEEPER PUNCTURES
CRUCIATE SUTURES PLACED TO GENTLY OPPISE SURFACES WITHOUT FULL CLOSURE. APPLIED SUPPLICAL AND E COLLAR
LRS SC 100ML
CONT WITH CLAVAMOX 1.5ML PO BID X 10 DAYS
NOLVASAN TO WOUND SID X 10 DAYS
E COLLAR WAS “PUT TOGETHER” ONTO PET AND WILL NOT SLIP OFF OVER HEAD. IT WILLL NEED TO BE DISASSEMBLED OR CUT TO BE REMOVED
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