STORM – A1109305
Safe - 4-22-2017 Manhattan
SAFE 4/22/17 STORM is a 6 month old maine coon mix who was brought in injured. Suspected high rise fall trauma and has some lameness on forelimbs and swollen paws. Is very affectionate and rolls over for attention. Needs further medical eval.
STORM – A1109305
FEMALE, GRAY, MAINE COON MIX,6 mos
STRAY – STRAY WAIT, NO HOLD Reason PETINJURED
Intake condition INJ MINOR Intake Date 04/18/2017, From NY 10455, DueOut Date 04/21/2017,
Medical Behavior Evaluation GREEN
Medical Summary DVM Intake Exam Estimated age:6 months History : brought in as a stray; trauma from suspected high rise trauma Subjective: BAR Observed Behavior – affectionate, interactive, rolls on back Evidence of Cruelty seen – none Evidence of Trauma seen – bilat forelimb lameness with swelling of paws, abrasion under nose Objective T =not taken P = WNL R = WNL BCS 4/9 EENT: Eyes clear, ears clean, no nasal discharge noted; abrasion under nose Oral Exam: mm pk, moist; CRT <2 sec; permanent upper canines coming in along side of deciduous teeth PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: female, no spay scar or tattoo noted MSI: ambulatory x 4 but with bilateral forelimb lameness, worse on RF; swelling over metacarpals bilaterally but no obvious fracture or instability; reluctant to walk due to discomfort on forelimbs; hair coat clean and free of parasites or lesions CNS: mentation appropriate – normal CP/withdrawal x 4 Rectal: not performed Assessment 1. Suspected high rise trauma 2. bilateral forelimb lameness (worse RF) Plan Buprenex BID onsior SID x 3 days radiographs of forelimbs suspect soft tissue injury to forelimbs (worse on the R); patient has good neurologic function with no signs of abnormal mentation and no obvious fractures Prognosis: good to excellent pending radiographs SURGERY: Okay for surgery
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