TITAN – A1107190
Safe - 4-11-2017 Manhattan
SAFE 4/11/17 Meet Titan: Titan came in with bite wounds of an unknown origin. Due to these bite wounds, he will require a 6 month in-home quarantine. The quarantine will require monthly vet visits for the first 4 months, and then calls to the Department of Health for the remaining 2 months. Other pets may live in the home with Titan but proof of rabies vaccination must be provided. If Titan leaves the five boroughs, written and signed permission must be obtained from the DOH of the county where he will be staying.
MANHATTAN CENTER
TITAN – A1107190
MALE, LYNX PT / WHITE, DOMESTIC SH MIX,3 yrs
STRAY – STRAY WAIT, HOLD FOR DOH-V Reason STRAY
Intake condition INJ MINOR Intake Date 03/27/2017, From NY 10466, DueOut Date 03/30/2017,
Medical Behavior Evaluation GREEN
Medical Summary DVM Intake Exam Findings History Subjective Observed Behavior – calm, allows handling Evidence of Cruelty seen – n Evidence of Trauma seen – y Objective P =200 R =wnl BCS 5/9 two abscesses:on right shoulder and left caudal thigh, muscles of thigh exposed EENT: Eyes clear, ears clean, no nasal discharge noted Oral Exam: wnl PLN: No enlargements noted H/L: NSR, 2/6 heart murmur, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: intact, 2 testis MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat CNS: mentation appropriate – no signs of neurologic abnormalities Assessment infected wounds, open heart murmur Plan: amoxiclav 1.2 ml bid x 10d rec clean and scrub +/- sedate unclear if wound will require surgical closure wounds are consistent with but not diagnostic for bite/scratch wounds from a cat vs cat fight
Weight 10.0
INTIAL EXAM
DVM Intake Exam Findings
History
Subjective
Observed Behavior – calm, allows handling
Evidence of Cruelty seen – n
Evidence of Trauma seen – y
Objective
P =200 R =wnl BCS 5/9
two abscesses:on right shoulder and left caudal thigh, muscles of thigh exposed
EENT: Eyes clear, ears clean, no nasal discharge noted
Oral Exam: wnl
PLN: No enlargements noted
H/L: NSR, 2/6 heart murmur, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G: intact, 2 testis
MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat
CNS: mentation appropriate – no signs of neurologic abnormalities
Assessment
infected wounds, open
heart murmur
Plan:
amoxiclav 1.2 ml bid x 10d
rec clean and scrub +/- sedate
unclear if wound will require surgical closure
wounds are consistent with but not diagnostic for bite/scratch wounds from a cat vs cat fight
Re Exam:
03/27/17 18:37
The abscessed wounds on the right shoulder and left thigh are probably due to a fight with another cat, but this assumption is largely based on the signalment of the cat (un-neutered male , outdoor cat) and not the nature of the wounds themselves. They could in fact have any number of origins and are probably greater than 7 days old.
03/27/17 16:40
addendum:
S: intake earlier today, presented at medical for clip and clean and re-assessment of wound
O:
5% dehydrated
EENT: AU mild debris, OU clear, mild mucoid dc at nares
Oral: mild dental tartar, no oral lesions
Int:
– L caudal thigh: approx 3cm diameter defect in skin with clean pink underlying mm and rounded skin edges and extensive pocketing
– R lat shoulder: approx 2 cm diameter defect in skin with clean pink underlying mm and rounded skin edges with extensive pocketing in every direction; second smaller similar wound just dorsal to the first
Lnn: WNL
CV: 2/6 left sided heart murmur, s&s pulses, pink moist mm
Resp: clear lungs, eupnic
Abd: SNP
UG: intact male, soft moderately-sized bladder
MS: 4x ambulatory, BCS 5/9
Neuro: QAR, no obvious neuro deficits, complete neuro exam not performed
A:
bite wounds of unknown origin
early URI vs other
P:
clipped area around wounds, flushed with sterile saline
1.0ml Enrofloxacin (22.7mg.ml) SQ SID x 5d
0.61ml Simbadol SQ SID x 5d
0.23ml Onsior SID x 3d
cbc/chem
sedate wound closure 3/28
px: good with appropriate wound treatment
03/28/17 09:21
Hx: bite wounds of unknown, URI, CBC = non regen anemia (23% in face of dehydration) neutrophilia mild monocytosis, Chem = WNL
S: was NPO’s for possible sedation and primary wound closure, fed this morning (surgery delayed based on BW results), interested but not eating (appears nauseous, licking lips and swallowing)
O:
5% dehydrated
EENT : no nasal discharge, mucoid brown OU discharge, OS chemosis and blephrospasm
Oral: no oral lesions
Int: a 3 wounds mildly hemorrhagic, exposed muscle clean and pink
Lnn: WNL
CV: 2/6 left sided heart murmur, s&s pulses, pale pink moist mm
Resp: lungs clear, eupnic
Abd: SNP
UG: intact male, soft moderately-sized bladder
MS: 4x ambulatory, BCS 5/9
Neuro: QAR, no obvious neuro deficits, complete neuro exam not performed
A:
bite wounds of unknown origin
non regenerative anemia (r/o chronic dz vs blood loss vs other)
URI
conjunctivitis
dehydration
P:
cwct
150ml LRS SQ SID x 3d
0.45ml Cerenia SQ SID x 3d
1.4ml Amoxiclav PO BID x 10d
terramycin OU BID x 7d
clean wounds with sterile saline
sedate wound closure 3/30
px: good with appropriate wound treatment
03/29/17 11:41
Hx: Bite wounds unknown. Non regenerative anemia, URI. On LRS, clavamox, cerenia, terramycin since 3/28. On baytril, simbadol, onsior since 3/27.
S/O) BARH. MM pk.
Ate well overnight. Normal UR.
A) Bite wounds.
P) CWPT. Sedate tomorrow for bite wound tx.
3/30
SEDATED EXAM FOR ABSCESSED WOUNDS
AWAKE EXAM PET IS DOCILE, TWO WOUNDS LOCATEDON RIGHT SHOULDER, ONEON LEFT HAUNCH
WOUNDS APPEAR WITH HEALTHY GRANULATION TISSUE, UNDERLYING MUSCULAR VISIBLE, SKIN SLIDES OVER MUSCLE BELLIES
SEDATED WITH IV DEXDOMITOR 0.1ML AND TORB 0.1ML IV
MAINTAINED ON ISO
WOUNDS DEBRIDED AND CLOSED WITH 3-0 PDS, VENTRAL WOUND MARGINS LEFT OPEN FOR DRAINAGE
PET’S EARS CLEANED MICROSCOPIC EXAM OF DEBRIS MITES FOUND
IVERMECTIN 0.1ML GIVEN SC
APPLIED OTOBIOTIC TO AU
P; CONT WITH CURRENT TX EXCELLENT PROGNOSIS
03/31/17 10:15
S: eating very well, primary closure of bite wounds yesterday
O:
well hydrated
EENT: no discharge AU/nares, mild epiphora
Oral: no ulceration
Int: wound on L lateral shoulder clean mild amount of hemorrhagic dc at open dorsal edge, primary closure intact; wound on caudal R thigh primary closure intact, ventral/distal edge of the wound open for drainage (minimal)
Lnn: WNL
CV: NMA, s&s pulses, pink moist mm
Resp: clear lungs, eupnic, no stertor
Abd: SNP
UG: male intact
MS: 4x ambulatory, BCS 5/9
Neuro: BAR, no obvious neuro deficits, complete neuro exam not performed
A:
bite wounds
uri
P:
cwct
px: good
Behavior:
KNOWN HISTORY:
Titan was brought into the care center as a stray with unknown history.
Other notes: During intake Titan was friendly, solicited attention, and allowed handling.
MEDICAL BEHAVIOR:
Observed Behavior – calm, allows handling
ENRICHMENT NOTES:
3/28/17
Curled up at back of cage, eyes dilated, drooling heavily. Allowed and slightly leaned into pets, closed eyes. No real response.
3/29/17
Ate offered treats. Seemed to pause eating whenever I stepped away. Lying at the back of the cage, eyes dilated but only half open, soft posture. Allowed, then leaned into pets and closed eyes.
EVALUATION:
Cage Condition: No change
Reaction to assessor: Titan remains crouched position on her cage bedding when approached by the assessor.
Reaction to cage door opening: Titan remains motionless with normal shape eyes.
Reaction to touch: While Titan accepts the stroke, she slowly places her head down and leans into the assessor’s hand.
ACTIVITY LEVEL: Mellow
VOCAL: Quiet
CHARACTER TYPE: Shy and Independent
POTENTIAL CHALLENGES:
Please note that this cat has a severe medical condition so we may not be seeing any true behavior and behavior may change when the cat’s medical condition improves.
RECOMMENDATIONS:
– Experienced cat parent
Titan tolerates attention and petting but may be fearful or stressed in the shelter. We recommend that this cat go to a home with experienced cat parents.
Enrichment:
3/28/17
URI, heart murmur, abscesses, possible bite wounds. Curled up at back of cage, eyes dilated, drooling heavily. Nauseous? Allowed and slightly leaned into pets, closed eyes. No real response. Sprayed feliway.
3/29/17
No drooling today! Empty food bowl seen in cage. Ate offered treats. Social eater? Seemed to pause eating whenever I stepped away. Laying at the back of the cage, eyes dilated but only half open, soft posture. Allowed, then leaned into pets and closed eyes.
3/30/17
Seems to be feeling much better! Laying on bedding, soft eyes and body, squinty. Leaned and arched very enthusiastically into pets, rolled all the way over.
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