WALTER – A1099079
Safe - 12-8-2016 Brooklyn Rescue: Big Hands Little Paws Please honor your pledges: http://bighandslittlepaws.org/donate/
Walter A1099079, Stray, 4 Years Old, Neutered, Gray Tabby/White DSH, 11.0 lbs
Cat hit by car.
Microchip scan neg.
O: Distressed, alert/responsive. mm=pink, moist, CRT<2 s.
ORAL: Intraoral bleeding, left max incisors missing, blood on hard palate but unable to fully visualize due to patient movement.
EENT: OS – buphthalmos, hyphema, periocular bleeding. Bilateral epistaxis.
H/L: HR=120, irregular rhythm. RR=48, lungs clear, no dyspnea.
ABD/UG: Neutered male. Abd palpation WNL.
MS: Ambulatory but ataxic. No palpable fractures. Nail on left hind digit 5 torn.
NEURO: Ataxic gait, falls to the left and circles to the left. Full neuro exam not performed due to patient’s painful condition.
INTEG: Abrasion on dorsum of head. Full, clean haircoat, no fleas/flea dirt.
A: Head trauma, ocular trauma OS, suspect hard palate fracture, wounds.
P: Buprenorphine S/R 0.2 ml SQ.
Flushed OS, appled Ofloxacin ophthalmic 1 drop.
Monitor condition during the day – if declines, rec. EHR.
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