SPRING – A1123604
Gone - 8-29-2017 Manhattan
GONE 8/29/17 Spring was found in the park and brought in because he seemed to be limping, bleeding from the mouth and having eye problems. She has multiple orthopedic injuries – old fractures – and needs full body xrays. She also may have glaucoma in the eye. Shelter recommending euth – needs immediate medical.
SPRING – A1123604
FEMALE, BRN TABBY, DOMESTIC SH MIX,4 yrs
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition EXAM REQ Intake Date 08/28/2017, From NY 10455, DueOut Date 08/31/2017,
Medical Behavior Evaluation GREEN
Medical Summary DVM Intake Exam Estimated age: 2-5 years based on dentition and overall appearance Microchip noted on Intake? Scanned neg on intake History : Found outside in a park, seemed to be limping, bleeding from the mouth and having eye problems Subjective: Calm, doesn’t move much, allows all handling with relaxed body Evidence of Trauma seen – Many – see below Objective QAR, BCS 4.5/9, mild muscle wasting in hind limbs, MMs pink EENT: OD: Buphthalmia, corneal opacity on ventral half of the cornea. Through dorsal half of the cornea – hazy, difficult to interpret what I see. OS: phthisis bulbi, moderate mucoid discharge, mild conjunctival injection. Clean ear canals. No nasal discharge. Scar below left nare that extends into lip. Oral Exam: Mild tartar. Left upper canine is fractured in half. Left lower canine is missing. Right upper canine is missing or fractured at the base. Right lower canine is complete but causing a wound on maxillary gingiva. PLN: No enlargements noted H/L: NSR, NMA, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: Female, no spay scar visible or palpable MSI: Walks slowly. Right elbow does not bend more than 5 degrees. Tail – first few vertebrae are fixed in place and then the tail takes a 90 degree bend ventrally. Pt resists raising the tail – appears to be painful. Healthy hair coat. CNS: Quiet, dull Rectal: Normal externally Assessment: 1. Glaucoma OD, phthisis OS (possibly end-stage glaucoma?) 2. Evidence of multiple orthopedic injuries in the past – right elbow and tail – likely fractures vs. congenital disease 3. Lip scarring Prognosis: Long-term prognosis is poor for this pt. Short term – managing pain and glaucoma may be possible. Plan: 1. Simbadol 0.3 ml SQ SID x10 days 2. Consider EHR 3. Otherwise, recommend medical treatment of glaucoma and whole-body rads SURGERY: Temporary waiver due to multiple medical issues. 1088
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