FRANCES – A1114990

Brooklyn Center

Frances A1114990 – 3 yr. neutered black cat, stray:

MEDICAL:

6/12:

S: Patient seem to be lethargic. Not eating or drinking.

Obj

5% dehydrated

EENT-Proptosed lright eye

Abdomen- NAF

MS- NAF

Neuro- amb in all 4 limbs

CV- NAF

Assessment- Proptpsed eye

Plan

Radiograph- pending

Bloodwork- pending

Enucleation and hospitalization is indicated

Continue TAB ophthal, 150 ml LRS sq SID , simbadol treatment meanwhile.

New hope- placement.

6/11:

DVM Intake Exam

Estimated age: 2-4 years?

Microchip noted on Intake? MC: 981020021156214

History : Injured stray

Subjective: 7% dehydrated, BAR

Observed Behavior – Vocal, very sweet, purring, tolerates all medical handling

Evidence of Cruelty seen – no

Evidence of Trauma seen – yes

Objective

T = 102.4 P = 180 R = 24 BCS 3/9

EENT: OD marked buphthalmia with proptosis, periocular hyperemia/alopecic, hemorrhagic crusting; OS enophthalmic, mucoid dc

Oral Exam: healing split palate; mandibular symphyseal laxity; mandibular maloclusion preventing closure of mouth, dentition quality is good; foul smell (unsure if coming from eye or mouth)

PLN: No enlargements noted

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

ABD: Non painful, no masses palpated

U/G: CM, small soft bladder

MSI: Ambulatory x 4, skin free of parasites, no masses noted, crusted material on front legs, very unkempt/dirty, moderate generalized muscle atrophy

CNS: mentation appropriate – no signs of neurologic abnormalities

Rectal: not performed

Assessment

2 year old CM DSH

1. Dehydration

2. Buphthalmia, proptosis suspect ruptured globe OD

3. Mandibular trauma (symphyseal fx +/- TMJ lux +/- other fractures), suspect difficulty eating due to maloclussion

4. Split palate – healing

5. Muscle atrophy

6. Dirty

Plan

1. IVC and start on 15 ml/hr overnight

2. Simbadol 0.24 mg/kg SQ SID x 5 days

3. Lubricate eye BID x 5 days

4. Convenia (in lieu of oral meds due to oral tauma) 8 mg/kg SQ

5. Needs Enucleation OD, needs mandibular x-rays +/- repair

6. Retro negative

7. Received vax, pyrantel, activyl, already has MC

8. Contac New Hope about placement

9. Get full blood work tomorrow when better hydration

10. Sign up for soft foods only

Addendum:

-IVC not patent; pulled, elect 200 ml SQ LRS for now

Prognosis: Fair pending surgical interventions

SURGERY: neutered

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