BENVOLIO – A1106572

MANHATTAN CENTER

FIV POSITIVE

BENVOLIO – A1106572

NEUTERED MALE, GRAY / WHITE, DOMESTIC SH MIX,4 yrs
STRAY – ONHOLDHERE, HOLD FOR DOH-V Reason STRAY
Intake condition INJ MINOR Intake Date 03/19/2017, From NY 11416, DueOut Date 03/22/2017,

Medical:

3/20

DVM Intake Exam Findings

scan neg on intake, MC placed

4yo MN DSH

History reported HBC, no obvious injuries noted on LVT intake overnight, placed in med for obs

Subjective

Observed Behavior – very sweet except resists when lower back palpated, eating well, observed defecating normally after exam

Evidence of Cruelty seen – no

Evidence of Trauma seen – wound on dorsum

Objective

T = P = 180 R = 20 BCS 7/9

EENT: Eyes clear, ears clean, no nasal discharge noted

Oral Exam: minimal dental tartar, no oral lesions

PLN: No enlargements noted

H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic

ABD: Non painful, no masses palpated

U/G: neutered male,

MSI: unable to observe gait, no obvious fractures palpable x4 limbs, vocalizes on lower back palpation, but no pain response on hip palpation, skin free of parasites, no masses noted, healthy hair coat, small (2mm) superficial hemorrhagic wound on dorsum at the level to T-L jnx just to left of midline

CNS: mentation appropriate – no signs of neurologic abnormalities

Rectal: no performed, observed defecating after exam, formed stool
Assessment

wound

suspect trauma

Plan

clip and clean wound on back

0.37ml Buprenex OTM BID x 3 days

recheck mobility and spinal palpation in 2days

consider sedated rads if issues continue

px: good

3/19

QAR

scan negative

neutered male

allows handling

reported HBC

no injury seen

AMB x 4

walking slow

sometimes respiratory noise

mild dehydration

mild tartar

clean EEN

clean coat

overweight

FIV positive

spoke to Dr and explained

Dr rec to give 125cc SQF

NOSF

Weight 12.0

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