REINA – A1125674
Urgent - Manhattan
FOSTER CARE 9/19/17 NEW PHOTOS! Reina was found under a car – possibly was hit – she has facial swelling and head trauma – needs xrays of head and further medical. She is about 6 mos old. Needs rescue.
REINA – A1125674
FEMALE, CALICO, DOMESTIC SH MIX, 6 mos
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition EXAM REQ Intake Date 09/16/2017, From NY 10456, DueOut Date ,
Medical Behavior Evaluation GREEN
Medical Summary DVM Intake Exam Estimated age: 2 yo Microchip noted on Intake? n History : stray, found under car- likely incurred trauma Subjective: facial swelling over frontal sinus, dried blood from nares Observed Behavior – QAR, easily handled Evidence of Cruelty seen – n Evidence of Trauma seen – yes Objective T = 103.7 P = 100 R = 20 BCS 5/9 EENT: severe subpalpebral inflammation OU, cannot perform menace OU, midriasis OU, ears clean, bloody mucoid discharge from nares Oral Exam: pink tachy mm w/ crt<2s, mild gingivitis over premolars, healthy adult dentition PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnec, stertorous breathing ABD: Non painful, no masses palpated U/G: female, need to establish spay status MSI: Ambulatory x 4, no open wounds or obvious fractures, skin free of parasites, no masses noted, healthy hair coat CNS: mentation dull – possible central blindness due to acute trauma, proprioception WNL x4, no palpable facial fractures Assessment: 1. head trauma- r/o facial fractures Plan: 1. skull radiographs 2. IV Catheter w/ LRS @ 5 ml/hr 3. simbadol injection 4. onsior injection Prognosis: guarded SURGERY: Temporary waiver due to trauma .
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