LEO aka MARS – A1108429
Safe - 4-12-2017 Manhattan
SAFE 4/12/17 LEO MAY HAVE FALLEN OUT OF A WINDOW – CAME IN INJURED
MANHATTAN CENTER
LEO aka MARS – A1108429
MALE, BLACK / WHITE, DOMESTIC SH MIX,10 mos
STRAY – PRE RTO, HOLD FOR RTO Reason PETINJURED
Intake condition INJ SEVERE Intake Date 04/10/2017, From NY 10467, DueOut Date 04/13/2017,
Medical Behavior Evaluation No Initial Behavior
Medical Summary DVM Intake Exam Estimated age: 9-12 mo Microchip noted on Intake? History : Presented as a stray, suspected to have fallen out of a window; no other history known Subjective: QAR Observed Behavior – Evidence of Cruelty seen – Evidence of Trauma seen – mild-mod amount of bloody, mucoid discharge coming from nostrils bilat Objective T = P = 80 R = 50 BCS 5/9 EENT: mucoid, bloody discharge coming from nostrils bilat Oral Exam: mm pale, moist; CRT >2 sec PLN: No enlargements noted H/L: bradycardic on presentation; increased resp rate with normal effort; normal BV sounds on L side but decreased on R side; grade III parasternal murmur appreciated ABD: Non painful, no masses palpated U/G: intact male MSI: Ambulatory x 4; no obvious fractures or instability of appendages or spinal palpation; mild soft tissue swelling over R antebrachium CNS: mentation appropriate; pupils dilated, responsive to light; normal CP/withdrawal x 4 Rectal:not performed Assessment 1. Trauma-r/o high rise syndrome vs other Plan Gave 0.4 ml buprenex after initial exam Rec’d full body radiographs Buprenex, onsior Monitor neurologic status for any changes Prognosis: good if no significant secondary injuries seen on radiographs SURGERY: Temporary waiver due to recent trauma Permanent waiver due to
Weight 0.0
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