MUFFIN – A1115301
Urgent - Manhattan
NEW PHOTO! MUFFIN was brought in dragging his right hind leg – he has hip fractures and may have other issues – needs medical eval with orthopedic vet – urgent rescue needed!
MUFFIN – A1115301
UNKNOWN GENDER, BRN TABBY, DOMESTIC SH MIX,1 yr
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition EXAM REQ Intake Date 06/14/2017, From NY 10458, DueOut Date 06/17/2017,
Medical Behavior Evaluation GREEN
Medical Summary DVM Intake Exam Estimated age: 1yr Microchip noted on Intake? none History : stray, HBC Subjective: Observed Behavior – painful, allows handling Evidence of Cruelty seen – no Evidence of Trauma seen – yes Objective P = 180 R = 78 BCS 5/9 EENT: Eyes clear, ears clean, no nasal discharge noted Oral Exam: pink gums, moderate tartar PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated, palpable feces in colon U/G: FI, no palpable MGTs, grossly normal MSI: Ambulatory x 4, but occasionally drags R HL, skin free of parasites, no masses noted, healthy hair coat, mild dehydration CNS: mentation appropriate – no signs of neurologic abnormalities, possible CP deficit in R HL, no spinal pain Rectal: normal anal tone Assessment trauma HBC FI dehydration approx 3-5% Plan 2v HL rads: no obvious long bone fx’s, L hip- body of L ilium with possible acetabular involvement, wing of L ilium appears displaced caudodorsally, possible fx of ischium and body of pubis. Feces in colon, bladder intact check urination, check defecation gave first dose buprenorphine 0.3mg/ml: 0.3ml IM given 3:45PM, then give BID x5 onsior 20mg/ml: gave 0.25mlSQ SQ at 4PM, then SID x2 more days LRS 75ml SQ SID x3 Prognosis: open- if p urinates and defecates on own, and can get orthopedic consult- good SURGERY: Permanent waiver due to hip fractures
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