MONTEBELLO – A1112721
Safe - 5-25-2017 Manhattan
SAFE 5/25/17 — 2 year old Montebello has a wound on his tail. He needs follow up vet care and a good home!
MONTEBELLO – A1112721
MALE, BRN TABBY / WHITE, DOMESTIC SH MIX,2 yrs
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition INJ MINOR Intake Date 05/21/2017, From NY 10467, DueOut Date 05/24/2017,
Medical Behavior Evaluation BLUE
Medical Summary DVM Intake Exam Estimated age: 2-3 years based on secondary sex characteristics Microchip noted on Intake? History : Stray, seems to have a hole in tail Subjective: Allows initial handling, calm. Hisses when tail is looked at (has wound). Towel-wrapped for clipping of tail – pt yowled and started to bite, so minimal cleaning was done. Objective BCS 5/9, MMs pink and moist EENT: Eyes clear, ears clean, no nasal discharge noted Oral Exam: Clean teeth PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: Male intact MSI: Wound to left side of tail about 2/5 of the way down – round full-thickness ulceration with brown tissue visible deep to wound. No discharge. The margins of the wound are contracted as if it is not new. A long linear scratch extends from the wound distally in a spiral fashion around the tail. Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat CNS: mentation appropriate – no signs of neurologic abnormalities Assessment: Tail wound Plan: 1. Clipped fur around wound during exam. 2. Sedate for wound cleaning and probing tomorrow. Will likely do delayed closure later in the week. 3. Simbadol 0.75 ml SQ SID x5 days 4. Amoxiclav 1.65 ml PO BID x10 days Prognosis: Good SURGERY: Okay for surgery 1088
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