TITO – 10412
Safe - 10-25-2017 Manhattan
SAFE 10/25/17 ***Must Leave Shelter by 6pm*** Tito has a fractured soft palate and needs a feeding tube, please help him today . Meet Tito: This handsome fellow was possibly hit by a car or could be suffering from high rise trauma. He has trauma to his head with a soft palate fracture and will need a feeding tube. Tito needs to leave the shelter by 6pm today, so please help this sweet boy today @MACC!
Manhattan Center
Tito 10412 3Y Gray Tabby DSH N
Stray Intake: 10/21/17
Initial Exam (10/21/17)
Exam
Estimated age: Did not want to open mouth – too painful
Microchip noted on Intake? scanned negative
History : HBC?
Observed Behavior – breathing through mouth only, can’t breathe through nose
Evidence of Cruelty seen – none
Evidence of Trauma seen – head trauma
Objective
T = 103.6
P = 200
R = 32
BCS = 5/9
EENT: upper left eyelid is ruptured, third eye lid on right eye is covering almost half of the eyeball, nosr badly injured
Oral Exam: potential broken jaw
ABD: Non painful, no masses palpated
MSI: Ambulatory x 4, skin free of parasites, no masses noted, healthy hair coat
CNS: Mentation appropriate – no signs of neurologic abnormalities
Patient stable
Called on call vet Dr. – communicated above, recommendation made to give simbadol (based on weight – gave 0.9 mls SQ, and place in cage)
Re-Exam (10/22/17)
DVM Intake Exam
Estimated age: 3-5 years
Microchip noted on Intake?
History : finder brought in injured cat that they had been feeding for a little while; he has not been seen for a few days but came back with apparent head trauma
Subjective: QAR
Observed Behavior -allows handling, appears docile despite being painful
Evidence of Cruelty seen -n
Evidence of Trauma seen – facial trauma
Objective
BCS 7/9
EENT: OU-severe traumatic conjunctivitis, blepharitis, bloody mucoid discharge; elevated 3rd eyelid; severe blepharospasm-unable to visualize globe OS
copious amount of dried bloody mucoid nasal discharge along nares, face and stained on forelimbs; mild active bloody, slightly mucoid discharge; severe nasal congestion
Oral Exam: mm pk, CRT 2 sec; severe hypersalivation with bloody discharge; holding mouth open-suspect due to nasal congestion; suspect fracture along soft palate with mild step; large laceration in tongue, likely bit it during trauma
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: tense on palpation, no obvious abnormalities
U/G: neutered male
MSI: appears ambulatory x 4 but reluctant to move/walk so difficult to assess; no obvious fractures or lameness noted
CNS: quiet mentation but appears interactive and responsive
Rectal: grossly normal
Assessment
Head trauma-suspect high rise trauma
Soft palate fracture
Tongue laceration
Prognosis: guarded to fair
Plan:
Gave 0.4 ml hydromorphone SQ
Place IVC, gave 100 ml bolus then continue at 20 ml/hr x 24 hours, then re-assess
Ofloxacin OU BID x 14 days
Simbadol 0.8 ml SQ SID, start this afternoon
Onsior 0.8 ml SQ SID x 3 days, gave first dose
Cerenia 0.8 ml IV SID x 3 days
Baytril 22.7 mg/ml: 3.6 ml IV SID x 3 days, switch to oral if doing well
SURGERY: neutered
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View all entries in: SAFE Cats 2017-10