BENJI – A1123072
Safe - 9-7-2017 Brooklyn
SAFE 9/7/17 Sleeping So Peacefully & Needing Your Help Today Meet BENJI @ BACC. BENJI was brought in with a large wound on the left side of his neck. He is very affectionate and needs a new home. Wound is healing and he should require minimal care.
BROOKLYN CENTER
BENJI – A1123072
NEUTERED MALE, ORG TABBY / WHITE, DOMESTIC SH MIX,2 yrs
STRAY – STRAY WAIT, NO HOLD Reason STRAY
Intake condition INJ MINOR Intake Date 08/23/2017, From NY 11208, DueOut Date 08/26/2017,
Medical Behavior Evaluation GREEN
Medical Summary DVM Intake Exam Estimated age: 2-3 Microchip noted on Intake? n History : stray Subjective: large wound one left side on ventral neck approx 5″ X 3″. at least 7 days old–no pus, evidence of healing by area of bladness around it. healthy granulation bed, dry scabs. wound consistant with burn but could be other trauma Observed Behavior – very affectionate. enjoyed rubbing of irritated area Evidence of Cruelty seen – n Evidence of Trauma seen – y Objective P = 160 R = wnl BCS 5/9 EENT: Eyes clear, ears clean, no nasal discharge noted Oral Exam: clean teeth PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: Non painful, no masses palpated U/G: intact male MSI: Ambulatory x 4, fleas. large healing wound on neck CNS: mentation appropriate – no signs of neurologic abnormalities Assessment: fleas, wound Plan: wound should heal with minimal intervention. oral antibiotics given but may not even be needed past 7 days. cleaned and manually debrided with chlorhex Prognosis: good SURGERY: Okay for surgery in house
Weight 9.7
Medical::
08/23/17:
DVM Intake Exam
Estimated age: 2-3
Microchip noted on Intake? n
History: stray
Subjective: large wound one left side on ventral neck approx 5″ X 3″. at least 7 days old–no pus, evidence of healing by area of baldness around it. healthy granulation bed, dry scabs. wound consistant with burn but could be other trauma
Observed Behavior – very affectionate. enjoyed rubbing of irritated area
Evidence of Cruelty seen – n
Evidence of Trauma seen – y
Objective
P = 160 R = wnl BCS 5/9
EENT: Eyes clear, ears clean, no nasal discharge noted
Oral Exam: clean teeth
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G: intact male
MSI: Ambulatory x 4, fleas. large healing wound on neck
CNS: mentation appropriate – no signs of neurologic abnormalities
Assessment: fleas, wound
Plan: wound should heal with minimal intervention. oral antibiotics given but may not even be needed past 7 days. cleaned and manually debrided with chlorhex
Prognosis: good
SURGERY: Okay for surgery in house
08/25/17:
Re-exam wound on neck
History : Intake 8/23-had large wound on right side of neck and live fleas noted
Subjective: BARH
Objective
P = wnl R = wnl BCS 5/9
EENT: Eyes clear, ears have moderate to severe amount of black/brown debris with AD>AS-very pruritic when touching ears, no nasal discharge noted
Oral Exam: moderate dental disease, no oral lesions noted
PLN: No enlargements noted
H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic
ABD: Non painful, no masses palpated
U/G: intact male, 2 testicles descended
MSI: Ambulatory x 4, no live parasites noted, ~8cmx5cm wound on right side of neck that has a healthy granulation bed and scabbing. No purulent d/c from wound. Hypothrichosis extends around neck and behind left ear as well
CNS: mentation appropriate – no signs of neurologic abnormalities
Assessment:
Otitis externa r/o ear mites
Large healing wound on right side of neck ~8cmx5cm r/o self trauma due to ear mites vs trauma
Plan:
Cleaned and manually debrided wound with chlorhex
Cleaned ears
Start tresaderm AU BID x14d
Recheck wound daily
Continue clavamox as directed
Applied revolution
Prognosis: good
SURGERY: Okay for surgery in house
Enrichment::
08/24/17:
Lying in back of kennel, relaxed. He allows petting along his head and body, leaning in and stretching. Rolls over onto side. He stands up with continued petting and comes forward. Loves treats. Friendly boy, allows all petting despite injury. Did well today! Sprayed feliway.
Profile::
08/23/17:
The cat was very friendly at the time of pickup
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View all entries in: Safe Cats 2017-09