THUMBALINA – A1113753
Gone - 6-1-2017 Brooklyn
GONE 6/1/17 Thumbalina was brought in by someone who said she couldn’t use her hind end – she is FIV positive, and has some issues with her limbs. Needs further assessment to see if there is any spinal or nerve damage, head trauma, etc.
THUMBALINA – A1113753
FEMALE, BLACK / WHITE, DOMESTIC SH MIX,8 yrs
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition INJ SEVERE Intake Date 05/31/2017, From NY 11417, DueOut Date 06/03/2017,
Medical Behavior Evaluation RED
Medical Summary DVM Intake Exam 5/31/17 Estimated age: ~8yrs, female Microchip noted on Intake? No History : Stray cat – finder said cat was unable to use hindend, was wet, and appeared painful Subjective: Observed Behavior – QAR. Head trembling. Laying in lateral recumency. Hissed, lunged with front end when approached — sedated with telazol 0.1ml IM Evidence of Cruelty seen – No Evidence of Trauma seen – Yes (questionable mobilty in hindend) Objective P = WNL R = WNL BCS 4/9 EENT: Eyes clear, ears clean, no nasal discharge noted Oral Exam: Moderate wear and gingivitis, broken canines PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: small soft bladder, larger soft mass cranial to bladder, gas in intestines U/G: Female MSI: Unable to assess mobility but limbs are not flaccid, possible deep pain even under sedation, no palpable fractures, areas of alopecia/healing wounds at dorsal cervical region, no other wounds noted CNS: Possible head tremors CT positive for FIV Radiographs: lateral and VD pelvic/spinal — no obvious fractures; decreased serosal detail at caudal ventral abdomen, gas filled colon displaced cranially, unable to visualize kidneys, spleen, bladder Assessment: Neurologic – R/O spinal/nerve damage from trauma vs impingement from mass vs other vs other, R/O head trauma vs other; FIV+; abdominal mass – r/o abnormal kidney vs intestinal mass vs other Plan: In medical for observation. Recheck tomorrow. Gave simbadol 0.39ml SQ Prognosis: Fair SURGERY: Permanent waiver due to neurologic
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