FRANK – A1114122
Safe - 6-14-2017 Manhattan
***SAFE 06/14/17***BEGINNER ALERT!!!Poor Frank was found injured in the sewer! He is injured – has lameness in his left hind leg and swelling on the toes – possibly hit by a car – needs further exam to determine extent of injury.
Manhattan Center
My name is FRANK. My Animal ID # is A1114122. – P
I am a neutered male black and white domestic sh. The shelter thinks I am about 2 YEARS
I came in the shelter as a STRAY on 06/03/2017 from NY 10460, owner surrender reason stated was STRAY.
06/12/2017 AT RISK MEMO
A1114122 Frank is At Risk for medical reasons (please see exam below)
MOST RECENT MEDICAL INFORMATION AND WEIGHT
06/11/2017 Exam Type RE-EXAM – Medical Rating is 4 NC – SEVERE CONDITIONS NOT CONTAGIOUS, Behavior Rating is NONE, Weight 10.2 LBS.
06/11/17 17:02 Hx: admitted with LHL lameness, Rads taken 6/7, no fx noted, bruising and ST swelling around L tarsus, neutered at that time, last day of SImbadol yesterday S: eating well, very easy to examine O: mildly hydrated 5% EENT: no discharge AU/OU/nares MS & Int: clipped LHL and inguinum, LHL tarsus slightly swollen, painful, toe touching to non wt bearing lameness Lnn: WNL H/L not asculted Abd: SNP UG: neutered male Neuro: BAR, no obvious neuro deficits, complete neuro exam not performed A: LHL lameness not improving soft tissue trauma vs inx arthritis vs autoimmune mild dehydration P: 100ml LRS SQ SID x3d 0.3ml Buprenex OTM BID x 5 days CBC Chem 01.0 ml Doxycycline po SID x 7 days px: good
06/03/2017 PET PROFILE MEMO
06/03/17 21:49 easy to handle
WEB MEMO
No Web Memo
06/06/2017 BEHAVIOR EVALUATION – BEGINNER
Exam Type BEHAVIOR
ACTIVITY LEVEL: Laid back VOCAL: Quiet CHARACTER TYPE: Calm, Sweet, Affectionate MEDICAL BEHAVIOR: 6/4/17- Observed Behavior – allows handling ENRICHMENT NOTES: 6/4/17- Asleep in litter box, still coming out of sedation. Stood and wobbled forward when door opened, soft eyes and body. Leaned and arched into pets, sniffed treats, started to eat slowly. EVALUATION: Cage Condition: No change Reaction to assessor: Frank immediately comes soliciting at the front of the cage. Reaction to door opening: Frank remains standing at the front of the cage, relaxed body posture, soliciting attention. Reaction to touch: Frank head-butts the assessor’s hand and appreciates petting on the head and body. Reaction to being picked up: Allows the pickup and remains calm. BEHAVIOR SUMMARY: Beginner Frank interacts with the Assessor, solicits attention, is easy to handle and tolerates all petting. This cat can go to a beginner home.
GROUP BEHAVIOR EVALUATION
No Group Behavior Summary
06/04/2017 DVM INTAKE PHYSICAL EXAM
Medical rating was 3 C – MAJOR CONDITIONS , behavior rating was NONE
DVM Intake Exam Estimated age: 2 years Microchip noted on Intake?placed on intake 981020021239705 History : found injured in the sewer Subjective: BAR Observed Behavior – allows handling Evidence of Cruelty seen – Evidence of Trauma seen – LH lameness, abrasions Objective P = 140 R = 35/eupnic BCS 5/9 EENT: Eyes clear, no nasal discharge noted AU-black discharge, very pruritic Oral Exam: mm pk, moist; CRT <2 sec; mild staining/tartar PLN: No enlargements noted H/L: NSR, NMA, CRT < 2, Lungs clear, eupnic ABD: soft, nonpainful; no palpable abnormalities U/G:male intact, 2 normal descended testicles MSI: LH-nonweight bearing lameness; swelling along metacarpals, hock coat covered in oily substance abrasions on upper and lower lip/chin CNS: mentation appropriate – no signs of neurologic abnormalities Assessment LH lameness-suspect HBC or other trauma ear mites Plan sedate with dexdomitor for rads, bathing continue simbadol 0.6 ml SQ SID x 7 days add onsior 0.45 ml SQ SID x 3 days was given ivermectin on intake, rec’d additional dose in 2 weeks Prognosis: open-pending radiographs SURGERY: okay for surgery
06/11/2017 RE-EXAM (LAST MAJOR EXAM)
Medical rating 4 NC – SEVERE CONDITIONS NOT CONTAGIOUS,
06/11/17 17:02 Hx: admitted with LHL lameness, Rads taken 6/7, no fx noted, bruising and ST swelling around L tarsus, neutered at that time, last day of SImbadol yesterday S: eating well, very easy to examine O: mildly hydrated 5% EENT: no discharge AU/OU/nares MS & Int: clipped LHL and inguinum, LHL tarsus slightly swollen, painful, toe touching to non wt bearing lameness Lnn: WNL H/L not asculted Abd: SNP UG: neutered male Neuro: BAR, no obvious neuro deficits, complete neuro exam not performed A: LHL lameness not improving soft tissue trauma vs inx arthritis vs autoimmune mild dehydration P: 100ml LRS SQ SID x3d 0.3ml Buprenex OTM BID x 5 days CBC Chem 01.0 ml Doxycycline po SID x 7 days px: good
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